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COPYRIGHT DEPOSIT. 



DISEASES 
OF THE INTESTINES 



BY 

Dr. I. BOAS 

SPECIALIST FOR G ASTRO-INTESTINAL DISEASES IN BERLIN 

SECOND REVISED AND ENLARGED AMERICAN EDITION. TRANSLATED 

BY PERMISSION FROM THE GERMAN EDITION, WITH 

SPECIAL NOTATIONS AND ADDITIONS 

SEYMOUR BASCH, M.I). 

M W VcikK ciTl 



WITH FORTY FIGHT ILLUSTRATIONS 



NEW YORK AND LONDON 
D. APPLETON AND COMPANY 

1 90 4 












\ 



LIBRARY of CONGRESS 
Two Copies Received 

MAY 24 1904 

Cooyrtfht Entry 
CLASB U~ XXo. No. 
COPY B l 



CorYUir.iiT. 1901, 1904, by 
L). AJPPLBTON AND COMPANY 



PRINTED AT THE APFLBTQjt 3*$B3Q / 

NEW YORK. V. S. A. 



PEEFACE TO THE SECOND AMERICAN 
EDITION 



It is gratifying to note the favorable reception of this translated 
work at the hands of the American profession. Within a very short 
time a large first edition has been exhausted. 

The translator has carefully gone over the entire publication, 
and made corrections and additions with a view of keeping the work 
up to the standard established by Dr. Boas. New chapters on 
Dysentery, Syphilis, and Actinomycosis of the Intestines have been 
added. 

In the preparation of this edition, valuable assistance has been 
given by Dr. A. D. Dryfoos of this city. 

S. Basch. 
1333 Madisox Avenue, 

New York. 

iii 



AUTHOR'S PEEFACE TO THE AMERICAN 
TRANSLATION 



It affords me great pleasure to make a few introductory 
remarks to this translation of my recently published Diagnostik 
und Therapie der Darinkran~kheiten. 

When the present book was written, the interest of the pro- 
fession in the pathology of the alimentary tract had already become 
very great. Owing to the ease with which diseases of the oesopha- 
gus and stomach could be investigated, these had been exten- 
sively studied. Because of their inaccessibility and the difficulty 
of judging the effect of treatment, our knowledge of affections 
of the intestine (exclusive, perhaps, of the rectum) was still very 
meagre. 

Notwithstanding that the classical publications of Woodward 
and Nothnagel, and the studies in ptomainology and the pathology 
of metabolism have done much to further our knowledge of in- 
testinal diseases, we have advanced but little since the days of 
Henoch, Bamberger, von Leube, and their contemporaries. 

Internal medicine must acknowledge a debt of gratitude to 
surgery, for the surgeon has contributed most to the progress 
that has been made. Our knowledge of appendicitis, intestinal 
obstruction and stenosis, and benign and malignant tumours has 
been greatly enriched by the results obtained from surgical treat- 
ment, and this progress is still going on. It is universally con- 
ceded that the American profession has contributed much toward 
this end, and in many parts of this work I have acknowledged 
this indebtedness. Numerous references to American authors will 
be found throughout the book. 



yi DISEASES OF THE INTESTINES 

It might be inferred from this that my treatise contains little 
that is unknown in America, but I trust that the American reader 
will find some useful diagnostic and therapeutic hints in the fol- 
lowing pages. 

I desire to express my thanks to my former assistant, Dr. Basch, 
for having undertaken and carried to a successful conclusion the 
work of translation. 

I trust that the American edition will meet with the same 
success that has attended the original in Germany. If it will 
aid the practitioner in solving some of the difficult problems in 
intestinal pathology and assist him in the treatment of his patients, 
the author will feel that his labours have not been in vain. 

I. Boas. 

Berlin. 



TRANSLATOR'S PREFACE 



The popularity which Dr. Boas's treatise has enjoyed abroad, 
and the absence in the English language of any detailed and 
exhaustive work on intestinal diseases, have led to the publication 
of the present translation. 

The book is intended more especially for the requirements of 
the general practitioner, but on account of the exhaustive and con- 
cise description of physiologico-chemical processes and laboratory 
methods, it must also prove of value to other scientific investigators. 

Additions have been made to the chapters on Appendicitis and 
Hydrotherapeutics, a special account given of the intestinal gases, 
and brief notes added in various parts of the book. These are 
indicated by [ ]. 

I wish to express my sincere thanks to Dr. S. ]S"euhof, of this 
city, for valuable assistance in the preparation of this work for 
the press, and to the publishers, D. Appleton and Company, for 
the many courtesies extended to me. 

S. Basch. 

48 East Sixty-third Street, 

New York. 

vii 



PREFACE TO THE FIRST GERMAN EDITION 



The present treatise is the final volume of the author's work on 
the diagnosis and treatment of the diseases of the gastro-intestinal 
tract. In this book I have closely followed along the lines laid 
down in my earlier work on Diseases of the Stomach. It has 
been my aim throughout to meet the requirements of the general 
practitioner. 

Without neglecting those diseases which are generally met with 
in hospital practice, I have given special prominence to the affec- 
tions which the private practitioner is called upon to treat — e. g., 
intestinal catarrhs and ulcers, duodenal ulcer, chronic constipation, 
rectal diseases, intestinal neuroses, etc. I have devoted no space to 
the discussion of intestinal parasites, and would refer the reader 
to standard text-books of medicine or the numerous monographs 
on the subject. 

In many of the chapters I have drawn upon my own experi- 
ence as gained both in a large polyclinic and hospital practice. I 
hope that I have been able to add some new and perhaps valuable 
facts to the pathology and treatment of intestinal diseases. 

While physical methods have been so thoroughly studied that 
only technical differences remain, examination of the faeces has 
heretofore been very much neglected. Whereas putrid sputa, 
badly smelling lochia, offensive secretions of uterine cancer in 
themselves no longer offer serious objection to examination, most 
physicians cannot accustom themselves to the analysis of the 
intestinal dejecta. This may in part be due to the circumstance 
that deductions can be drawn only after repeated careful exami- 
nations. This latter consideration should not, however, influence 



PREFACE TO THE FIRST GERMAN EDITION j x 

the conscientious physician, for urine and sputum, too, are very 
often examined with negative results. 

Since many intestinal diseases may require surgical interference 
at any moment, I have felt it necessary in a number of chapters to 
define my position in this respect. As an internal practitioner I 
have naturally little sympathy with extreme radical measures, and, 
with increasing experience, believe with conservative surgeons 
that we have almost reached the limits of possibility in intestinal 
surgery. 

As in diseases of the stomach, abdominal surgery has also made 
considerable advance within the last decade in diseases of the in- 
testines. If the medical practitioner wishes to keep abreast of 
progress he must follow these advances with the greatest con- 
scientiousness, and consider carefully the changes made from time 
to time in surgical technic, noting the results obtained there- 
from. Should he have the good fortune to be associated with 
a skilful abdominal surgeon, he should use every opportunity to 
witness operations upon the intestine. This sharpens the judg- 
ment, demonstrates the knowledge or ignorance of surgery, and 
indicates to us, even better than cumbersome and frequently col- 
oured statistics, the manner in which we must proceed in serious 
cases. As I have already stated in another place, I must again 
emphasize that the indications for operative procedures in diseases 
of the stomach and the intestines, as well as of the liver and gall 
bladder, is a matter which rests mainly with the medical practi- 
tioner. He should bear the responsibility for the operative inter- 
ference, while the surgeon should be responsible for the technic. 
The placing of the responsibility in one's hands implies the 
greatest confidence on the part of the patient and his family, and 
the medical practitioner can only accept such responsibility when 
he has recognised the disease in time, and is in a position to judge 
whether or not a surgical procedure is indicated, and with what 
prospects of success. 

In discussing these difficult and very important questions, I 
have agreed in most respects with the views of early writers. 



X DISEASES OF THE INTESTINES 

In stating niy views I have endeavoured to include theirs. In 
this connection I feel called upon to express my admiration for 
the epoch-making treatise on intestinal diseases of Professor 
Nothnagel, of Vienna, and my appreciation of his classical 
studies on the physiology and pathology of the intestines. 

Finally, I take great pleasure in acknowledging my thanks to 
my publisher, Mr. George Thieme, of Leipsic, for the careful 
preparation of the work. I desire also to thank Miss Paula 
Gunther, of Berlin, and my former assistant, Dr. Peitzenstein, 
of Nurnberg, for the excellent execution of the drawings. 

The Authok. 
Berlin. 



CONTENTS 



PAGE 

Author's preface to the American translation iii 

Translator's preface v 

Preface to the first German edition vi 



INTRODUCTORY 

CHAPTER 

I. — Preliminary anatomical and histological remarks ... 1 

Appendix. Displacements of various segments of the intestines 20 

II. — Preliminary physiological and physiologico-chemical remarks . 24 

[The intestinal gases] 46 



PART I 
GENERAL DIVISION 

III. — The history 55 

IV. — The examination of the patient 67 

Appendix. The employment of Rontgen rays in the diagnosis of 

intestinal diseases 88 

V. — Examination of the f^ces 90 

VI. — Diagnostic value of the examination of stomach contents in 

intestinal diseases 129 

VII. — Diagnostic value of urinary examinations in intestinal dis- 
eases 132 

GENERAL THERAPEUTICS OF INTESTINAL DISEASES 

VIII. — The dietetic treatment of intestinal diseases .... 139 
IX. — The hydrotherapeutics of intestinal diseases [including mineral 

WATERS OF THE UNITED STATES] 158 

X. — Massage. Electro- and hydrotherapeutics in intestinal diseases 170 
XI. — Injections (enemata, intestinal lavage, and douches), inflation, 

AND GASTRIC LAVAGE IN INTESTINAL DISEASES 177 

XII. — Medicinal treatment of intestinal diseases 186 

xi 



xii DISEASES OF THE INTESTINES 



PART II 
SPECIAL DIVISION 

CHAPTER PAGE 

XIII. — Acute and chronic intestinal catarrh 205 

XIV.— [Dysentery] 240 

XV. — Habitual constipation. Displacements of the intestines . . 272 

XVI. — Ulcers of the intestines 293 

XVII. — Round ulcer of the duodenum 312 

XVIII. — Intestinal neoplasms 328 

XIX. — [Actinomycosis of the intestines] 374 

XX.— [Syphilis of the intestines] 377 

XXL— Intestinal stenosis and intestinal obstruction .... 380 

XXII. — Typhlitis, perityphlitis (appendicitis) 468 

[Brief resume of the American views on appendicitis] . . 504 

Appendix. Sigmoiditis and pericolitis 511 

XXIII. — Diseases of the rectum 520 

XXIV. — Nervous diseases of the intestines 559 

List of subjects 581 

List of authors . 595 



LIST OF ILLUSTRATIONS 



FIGVRE PAGE 

1. Anterior view of the abdominal viscera . . . ■ . . . 2 

2. Perpendicular section of adult human jejunal mucous membrane . . 6 

3. Intestinal epithelium 7 

4. Section of mucous membrane of human duodenum 7 

5. Surface of mucous membrane of the small intestine 9 

6. Cross section of intestinal mucous membrane 9 

7. Section of mucous membrane of the small intestine through a Peyer"s 

patch 10 

8. Anterior view of the abdominal viscera after removal of the jejunum and 

ileum 11 

9. Opening of the ileum into the large intestine 13 

10. Male pelvic organs, viewed from the right side 17 

11. Herzstein's rectoscope . 81 

12. Spirals of undigested meat fragments in faeces 98 

13. Different vegetable substance found in faeces 114 

14. Fatty stools, showing a large amount of fatty acid crystals . . . 115 

15. Fatty soaps in faeces 116 

16. Normal and degenerated epithelial cells from the mucous shreds of a 

case of membranous enteritis 118 

17. Faeces from a case of chronic enteritis, showing sarcinae .... 120 

18. Bacillus butyricus (Clostridium butyricum) stained with iodin . . 122 

19. Charcot-Leyden crystals from faeces 123 

20. Yellow calcium salts from faeces 125 

21. Bismuth crystals from faeces 126 

22. [Position of hands and direction of movements in abdominal massage] . 171 

23. Electric rectal tube 174 

23a. {Rectal electrode] 175 

24. Vermiform appendix in contact with the under surface of the liver . 289 

25. Vermiform appendix lying behind the right lobe of the liver . . . 290 

26. Double looping of the transverse colon 291 

27. Double looping of the sigmoid flexure 291 

28. Multiple looping of the sigmoid flexure 292 

29. Tuberculosis of the caecum 297 

30. Multiple polypi of the rectum 366 

31. Ulcer of the duodenum, with secondary stenosis of the second portion 

and dilatation of the first portion . . . . • . . . . 389 

32. Strangulation by a broad peritoneal band passing between two adjacent 

coils of ileum ' 409 

33. Strangulation of small intestine by a solitary band attached at either end 

to the mesentery 409 

xiii 



xiv DISEASES OF THE INTESTINES 

FIGURE PAGE 

34. Strangulation of a small intestinal coil by a long ligamentous strand . 410 

35. Internal strangulation of an intestinal coil by a strand passing from the 

omentum or transverse colon to the anterior abdominal wall . . 410 

36. Internal strangulation of a loop of small intestine by a Meckel's diver- 

ticulum coiled about it 411 

37. Sigmoid flexure showing a tendency to volvulus formation . . . 415 

38. A. Type rectum en arriere. B. Type rectum en avant .... 415 

39. Schematic drawing to illustrate a knotting together of ileum and sig- 

moid flexure 417 

40. Schematic drawing to illustrate a simple intestinal invagination . . 421 

41. Ileo-caecal intussusception 423 

42. Complete rectal fistula 526 

43. Incomplete internal rectal fistula 526 

44. Incomplete external rectal fistula 526 

45. Tubercular anal and rectal ulcer, with hemorrhoidal nodule . . . 533 

46. Rectal support 546 

47. Peristaltic restlessness of the small intestines and descending colon . 564 



INTRODUCTORY 



CHAPTEE I 

PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS* 

The intestinal canal is that portion of the alimentary tract which 
is situated below the pylorus. The small intestine has for its main 
function the digestion of unassimilated food ; the large intestine 
serves for the reception and propulsion of undissolved and waste 
food products until their expulsion from the body. Occasionally 
the large bowel, especially the rectum, is called upon to digest and 
absorb nourishment, but this vicarious process of nutrition is not 
adequate to support life a long time. 

SMALL INTESTINE 

The small intestine, a small, thin-walled tube about 7 metres 
long, extends from the pylorus to the right iliac fossa, where, after 
becoming extremely convoluted, it finally opens into the large intes- 
tine. It is divisible into three portions, which vary as regards length 
and calibre — viz., duodenum, jejunum, and ileum. 

1. Duodenum 

The duodenum, about 30 centimetres long and 4 to 6 centimetres 
wide, is the widest and at the same time least movable portion of 
the small intestine. It describes a horse-shoe curve, the convexity 
of which is directed toward the right and downward, its concavity 
embracing the head of the pancreas. Owing to its peculiar form 
the duodenum is divided into three segments : superior horizontal 
portion (pars horizohtalis superior), a descending portion (pars 
descendens), and an inferior ascending portion (pars horizontalis 
inferior) (sen oblique ascendens, seu transversa). 

The pars horizontalis superior, the shortest division (5 centi- 
metres long), commences at the pylorus at the level of the first 

/* In writing the present chapter use has been made of the more popular text- 
books of anatomy, especially A. Rauber's Lehrbuch der Anatomie, Leipzig, 1892. 



2 DISEASES OP THE INTESTINES 

lumbar vertebra. From here it passes slightly upward, backward, 
and to the right, thus gaming the right side of the vertebral column. 
Ascending to the neck of the gall bladder, it then bends abruptly 




Fig. 1. — Anterior View of the Abdominal Viscera ( l / 5 ). 
(The liver is turned upward, thereby drawing the stomach and duodenum slightly 
upward and to the right.) 1, left lobe of liver; 2, lobus quadratus; 3, right lobe of liver; 
4, gall bladder; 5, round ligament of liver; 6, fundus of stomach; 7, greater curvature; 8, 
lesser curvature ; 9, horizontal portion of duodenum ; 10, descending portion of duodenum ; 
11, lesser omentum ; 12, spleen ; 13, jejunum ; 14, ileum ; 15, ascending loop of ileum ; 16, 
csecum ; 17, vermiform appendix ; 18, ascending colon ; 19, hepatic flexure ; 20, transverse 
colon ; 21, splenic flexure ; 22, descending colon ; 23, sigmoid flexure ; 24, bladder. (Eauber.) 

downward, and is continued as the pars descendens. The superior 
horizontal portion is invested by peritoneum, both anteriorly and 
posteriorly, and behind is in relation with the hepatic duct and the 






PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 3 

blood-vessels passing to the liver (the portal vein and the hepatic 
artery). This part frequently is found stained with bile. 

The 'pars descendens duodeni, which begins at the neck of the 
gall bladder, is twice as long as the first portion. It passes almost 
vertically downward in front of the right kidney and to the right of 
the vertebral column, about as far as the third or fourth lumbar 
vertebra. The transverse colon crosses at right angles in front of 
it. The common bile duct opens into the descending portion just 
before the latter merges into the pars horizontalis inferior. The 
duct descends behind the left border of the descending portion, and 
then, together with the pancreatic duct, which accompanies it for a 
short distance, penetrates the wall of the gut. Thus a kind of 
longitudinal swelling is formed, at whose lower end the common 
opening of the ducts is situated. This opening is frequently hol- 
lowed out — the diverticulum Vateri. 

The lower transverse portion — the pars horizontalis inferior, 
or, more correctly, the pars ascendens — equals or even exceeds in 
length the portion just described. It ascends obliquely from right 
to left, reaching the left side of the second lumbar vertebra, where, 
making a sharp bend — the flexura duodeno jejunalis — it merges 
into the jejunum. It passes behind the origin of the transverse 
mesocolon and the mesentery, while the abdominal aorta and the 
vena cava lie in front of this division. A short, fibrous, muscular 
strand, derived from the left crus of the diaphragm (the suspensory 
muscle of the duodenum), retains this portion of the duodenum in 
place. Thus, in contrast to the stomach, and especially to the large 
intestines, the duodenum is usually fixed ; nevertheless, as a result 
of marked distention and traction, it may descend to a greater or 
lesser degree. 

2. Jejunum and Ileum 

The jejunum and ileum, which together have received the name 
of intestinum mesentericum, merge into each other without any 
sharply defined line of separation. Formerly the term jejunum was 
applied to those portions of the small intestines which lie in the 
umbilical region and in the left iliac fossa, while the ileum included 
the portions in the right half of the abdomen, in the right iliac fossa, 
and in the pelvis. There are no marked differences in the structure 
of these two divisions. According to Hyrtl, three fifths of the 
small intestine below the duodenum constitute the jejunum and the 
remaining two fifths the ileum. The great mobility of the small 



4 DISEASES OF THE INTESTINES 

intestines does not permit of any constant position of the coils, but 
in general the upper coils lie more transversely and the lower more 
vertically. This mobility, however, is of the greatest practical im- 
portance ; it allows of the adaptation of the intestines to the most 
diverse conditions of the abdominal cavity, and also of their gliding 
aside when the cavity is filled with serous or other effusions. 

The mesentery, which binds the ileo-jejunum to the spinal col- 
umn, is of great importance. Fan-shaped, it spreads from its origin 
{radix mesenterii) and lies in many folds. Its edges are attached to 
the small intestines by means of a small slip, the mesenteric border. 

Blood-vessels, lymphatics, and nerves run between the two layers 
of the mesentery. They enter the wall of the intestines at the 
mesenteric border and terminate at the opposite free side. 

The arteries supplying the duodenum are derived partly from 
the coeliac axis and partly from the superior mesenteric artery, as 
follows : The coeliac axis gives off the hepatic artery, which sup- 
plies the liver. The gastro-duodenal branch of the hepatic artery 
passes behind the stomach at the junction of the pylorus and the 
horizontal portion of the duodenum, and in turn gives off the pan- 
creatico-duodenalis superior, which supplies the duodenum and the 
pancreas. In addition to the latter vessel the duodenum is also 
supplied by the pancreatico-duodenalis inferior, a branch of the 
superior mesenteric artery. The latter vessel passes beneath the 
pancreas, while its branch (the pancreatico-duodenalis inferior) 
winds upward and to the right, passing between the lower half of 
the duodenum and the head of the pancreas, and ultimately anasto- 
moses with the pancreatico-duodenalis superior. 

The jejunum and ileum are supplied by branches of the superior 
mesenteric {arterial intestinales). They pass between the layers of 
the mesentery, dividing forklike, and finally form a rich capillary 
network throughout the entire intestinal wall. The lower end of 
the ileum alone receives its blood supply from branches of the ileo- 
colic (colica-dextra), which latter, in part, also supply the cnecum and 
the vermiform process, and, in conjunction with the superior mesen- 
teric, the lower end of the ileum. 

Thus, we see, a dense network of the most delicate blood-vessels 
extends throughout the entire mesentery of the small intestines, 
piercing the muscular layers of the gut and penetrating to the sub- 
mucosa, where a second network is formed which supplies the 
mucous membrane, the folds, villi, and glands of the mucosa. 

The veins which carry the blood from the intestines into the 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 5 

portal vein have a course differing somewhat from their correspond- 
ing arteries ; viz., the branches corresponding to the gastro-dnodenal 
artery (i. e., the gastro-epiploica and the pancreatico-duodenal) empty 
into the superior mesenteric vein. 

The lymphatics may be divided into two sets, a superficial and 
a deep. The superficial originate in the muscularis (subserous 
lymphatics), while the deeper originate in the mucous membrane, 
the villi, and the solitary follicles (submucous lymphatics). Both 
sets unite at the mesenteric border of the small intestine and then 
pass between the layers of the mesentery. Owing to their physio- 
logical significance, they are called lacteals. 

The nerves of the small intestines are derived chiefly from the 
superior mesenteric plexus of the sympathetic. The hepatic plexus, 
an offshoot of the coeliac plexus, gives branches to the duodenum. 
Furthermore, the small intestine is supplied by the abdominal por- 
tion of the vagus ; viz., the anterior and posterior gastric plexuses. 
The nerves, which are for the most part non-medullated, accompany 
the branches of the superior mesenteric artery to the intestinal wall, 
and there form a subserous meshwork ; they then pierce the longi- 
tudinal muscular layer, forming between the latter and the circular 
layer a network consisting of numerous multipolar cells — the mes- 
enteric plexns of Auerbach. 

From the latter delicate nerve branches supply the muscularis ; 
others penetrate the circular muscular layer to the submucosa, 
where they form the submucous or Meissner nerve plexus — a very 
fine network of nerves containing small ganglion-cell groups. 
Bundles of nerve fibres pass from this plexus to the muscularis 
mucosae and to the muscularis of the villi, and are then lost in the 
mucous membrane. 

Histology of the Small Intestine 

The wall of thcsmall intestine is composed of four coats : tunica 
serosa, muscularis, submucosa, and mucosa (Fig. 2, page 6). 

The serous coat (peritoneum), as has been already mentioned 
(page 2), does not uniformly invest the small intestines. Practically 
speaking (and this is especially of surgical interest), the descending 
portion of the duodenum is covered only upon its anterior surface 
by the serous layer, while the superior and inferior horizontal por- 
tions are inclosed by both folds of the mesocolon. The serous layer 
is most adherent at the free border of the intestines, and but loosely 
adherent at the mesenteric border. 
2 



DISEASES OF THE INTESTINES 



The muscularis of the intestines consists of two layers of un- 
striped muscle fibres: a thick inner circular, and a thin external 
longitudinal layer. Toward the ileum the layers gradually become 
thinner. 

Artifacts 
Perpendicular section of the villi 




Epithelium 



Tunica 
propria- 



Muscularis 
mucosae, 



Submucosal''"- "*< '!/ \ \ 

Intestinal glands Oblique section of intestinal glands 

Fig. 2. — Perpendicular Section of Adult Human Jejunal Mucous Membrane ( x 80). 
During fixation the tunica propria of the villi retracted and became separated from the 
epithelium, thus causing a space at a and a tear at b. The dark spots in the villi, at the 
right-hand side of the figure, are goblet cells. (After Stohr.) 

The submucosa is composed of loose retiform tissue, and sup- 
ports the above-described numerous blood and nerve plexuses. 
The muscularis mucosae consists of smooth muscle fibres, an inner 
circular and an outer longitudinal layer. From it fibres pass per- 
pendicularly and inwardly, almost reaching the apices of the intes- 
tinal villi. By their contraction they may cause shortening of the 
villi. 

The epithelium of the mucosa (Fig. 3) consists of a single layer 
of cylindrical cells. We may distinguish two forms : cylindrical 
epithelium with a basement membrane, and the goblet cells. The 
significance of this basement membrane is still a matter of contro- 
versy. According to the latest investigations, we must here recog- 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 




,Jm 



A B 

Fig. 3. — Intestinal Epithelium ( x 560). 
A, goblet cells of rabbit (at x protrusion of mucus) ; 
B, portion of a section of human small intestine ; i, a goblet 
cell between cylindrical cells. (Stohr.) 



nise a very delicate skeletal framework with free interspaces ; through 
these latter, very fine protoplasmic prolongations of the epithelial 
cells can be thrust 
and again withdrawn. 
Thus, the chief seat of 
absorption is evident- 
ly in the basement 
membrane of the epi- 
thelial cells. The 
goblet cells have an 
oval, not infrequent- 
ly a gobletlike, form, 
the upper (free) part 
being more or less filled with mucus, which results from a proto- 
plasmic metamorphosis, while the nucleus lies at the base of the 
cell. They have no basement membrane, but have a sharply 

defined opening at their free border, 
through which the mucus is poured 
into the intestines. Leucocytes are 
present in varying numbers between 
the epithelial cells. 

The tunica propria consists main- 
ly of reticular connective tissue, with 
here and there numerous leucocytes. 
Owing to the size and number of the 
glands of the large intestines, the 
tunica propria is insignificant form- 
ing little more than the intervening 
substance between the glands and a 
narrow strip of basement substance. 
In the small intestines the tunica pro- 
pria forms numerous cylindrical pro- 
jections from the inner surface of the 
gut, the projections being 0.5 to 0.7 
millimetre in height and 0.1 to 0.2 
millimetre in width ; these are the 
so-called intestinal villi (Fig. 4). In 
the duodenum they are leaflike in 
shape. To a certain extent their 
functions are like those of the roots of trees, inasmuch as they dip 
directly into the nutritive material in the intestinal canal, and absorb 




a b a 

Fig. 4. — A. Section of Mucous Mem- 
brane of Human Duodenum 

(x 10). 

a, villi ; £>, basement substance of 
the mucous membrane; c, Brunner's 
glands ; d', deepest layers of the sub- 
mucous tissue. 

B. Transverse Section of Isolated 
Glands. 
a a, with lumen ; 5, without lu- 
men. (Bauber.) 



8 DISEASES OF THE INTESTINES 

all of it thereof that can be taken up (A. Kauber). The total num- 
ber of villi is estimated as over ten million. Each villus contains a 
central chyle space, or villous sinus, which is a club-shaped expan- 
sion of the lacteals of the intestinal mucous membrane, and is lined 
with endothelium. The larger villi contain several of these spaces. 
The blood-vessels of the villi spread out in the reticular tissue 
between the external and internal endothelium. This rich capillary 
network may cause erection of the villi, while the previously men- 
tioned offshoots from the muscularis mucosae cause their rhyth- 
mical contractions. Thus the villi act as simple and yet complete 
suction pumps. The villi are most numerous in the duodenum, 
gradually diminishing in number in the ileum. Each villus receives 
its blood supply from one or more arterial branches which, dividing, 
form a meshwork near the epithelium, from which meshwork the 
corresponding vein arises. 

A similar arrangement, intended for the greatest possible absorp- 
tion and a uniform distribution of nutritive material, is found in the 
so-called folds of Kerckring (valvulce conniventes Kerckringii). 
These occupy one half to two thirds of the transverse circumference 
of the mucous membrane, and are found close together in the upper 
third of the small intestine. They are absent in the upper third of 
the transverse portion of the duodenum. They number about eight 
hundred, and the distances between the individual folds, according 
to Sappey, average 15 millimetres. In the upper third of the small 
intestines their height and the intervals between them are uniform ; 
in the middle they diminish both in height and breadth, and finally 
disappear in the lowermost coils of the ileum. 

Glands form another constituent of the mucous membrane of 
the small intestines. The liver and the pancreas should be reckoned 
among these, since their secretions form an important — indeed, an 
indispensable — part of the intestinal juices. Since these are inde- 
pendent abdominal organs, their structure can not be entered into 
here. We have already discussed the openings of the ducts of these 
glands (page 3). The glands proper of the intestines are of two 
varieties : secretory and agminated. The first variety includes 
Brunner's and Lieberkuhn's glands ; the second variety includes 
the so-called solitary blind follicles and Peyer's agminated glands 
(Peyer's patches). Brunner's glands (Fig. 4), which are found 
almost exclusively in the upper part of the duodenum, are spread 
over an area of from 8 to 10 centimetres from the pylorus. They 
are conglomerate tubular glands whose bodies lie within the sub- 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 9 




Fig. 5. — Surface of Mucous Membrane of 
the Small Intestine. 
1, openings of Lieberkuhn's glands ; #, villi. 
(Rauber.) 



mucosa. Their terminal portions are lined with cylindrical cells 
having a lightly coloured granular protoplasm and an oval nucleus 
which lies near the periphery. The cells are best found by dissect- 
ing away the muscularis from without. 

In structure, Lieberkuhn's glands (Figs. 5 and 6) resemble closely 
the tubular glands of the stomach ; they are evidently the true se- 
creting glands of the small in- 
testines. They are present in 
enormous numbers throughout 
the mucous membrane of both 
small and large intestines. They 
are club-shaped and rounded off 
both above and below. Like the 
glands of the stomach, they are 
also seldom branched. They 
measure from 0.3 to 0.4 milli- 
metre in length, their total num- 
ber being estimated by Sappey 
at forty to fifty million. Ac- 
cording to Drasch, the glands 

are surrounded by a fine network of capillaries and nerves. They 
generally terminate in circular openings between the villi, and when 
viewed with a lens give the mucous membrane a honeycomb appear- 
ance. As is well known, the solitary lymph nodules (solitary fol- 
licles) are also met with in the 
oesophagus and stomach. They 
are quite . uniformly distributed 
throughout the surface of the 
small intestine. They have an 
elongated oval shape and are as 
large as millet seeds, but under 
pathological conditions may reach 
the size of a pea, or even larger. 
They extend deeply below the sub- 
mucosa. As regards their finer 
structure, this consists of adenoid 
tissue and usually contains a ger- 
minal centre. The leucocytes so 
frequently present in the follicles 
may pass into the lymphatic vessels or, by piercing the epithelium, 
may enter into the lumen of the intestines. 




6. — Cross Section of Intestinal 
Mucous Membrane (x 150). 
Showing Lieberkuhn's glands with 
their epithelial cell-lining embedded in 
the adenoid tissue of the raucous mem- 
brane, from which the cells are partially 
absent. (Rauber.) 



10 



DISEASES OF THE INTESTINES 



Peyer's patches occur in the ileum as elongated plaques, from 
2 to 10 centimetres in length and from 1 to 3 centimetres in 
breadth, their long axis corresponding to that of the gut. They 
are never situated at the mesenteric border. Occasionally they are 
met with in the jejunum, or even higher up, in the duodenum. 
Usually twenty to thirty such plaques are present. They are made 
up of groups of solitary nodules spread out over a flat surface (Fig. 
7) ; occasionally they become flattened from pressure. The mucous 
membrane covering the glands is, as a rule, thrown into folds, but 
it has no villi. Villi are, however, frequently present as flat folds 
upon the intervening elevations (Henle). 




Fig. 7. — Section - of Mucous Membrane of the Small Intestine through a Peyer's 
Patch, the Chyle Vessels being Injected. 
a, villi; c, follicles; d, projections of the latter toward the surface; g, h,i, lymphatic 
network around the follicles ; Jc, efferent blood-vessels. (Frey.) 



The branches of the chyle vessels form numerous meshes about 
the glands, and communicate with them by means of very delicate 
projections. These projections permit the passage of newly formed 
lymph cells into the lymph channels, for Peyer's patches are breed- 
ing places for lymph cells (A. Rauber). 



LARGE INTESTINE 

The large intestine (Fig. 8, page 11), the lower division of the 
intestinal canal, commences in the right iliac fossa, and thence 
ascends along the right posterior wall of the abdomen to the right 
hypochondrium. Here it comes in contact with the under surface 
of the liver, and, bending to the left, passes transversely and slightly 
upward to the spleen. There, in the left hypochondrium, it bends 
downward and descends along the left side of the abdomen to the 
left iliac fossa, and thence onward into the pelvis. The large intes- 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS H 

tine measures about 1.5 metres in length (according to Sappey, 
exactly 1.68 metres), and varies in diameter from 5 to 8 centimetres. 
Its diameter gradually diminishes from the csecum downward. The 




Fig. 8. — Anterior View of the Abdominal Viscera after Removal of the Jejunum 

and Ileum ( x 1 / 5 ). 
(Liver and stomach are turned up, the jejunum and ileum, excepting their two ends, 
removed, the mesentery is retained). 1, left lobe of liver; 2, lobus quadratus; 3, right lobe 
of liver ; 4, gall bladder ; 5, round ligament of liver ; 6, fundus of stomach ; 7, greater curva- 
ture; 8, lesser curvature ; S, pylorus; iO, duodenum : li, pancreas ; 12, spleen; 13, jejunum; 
14, mesentery ; 15, ileum ; 16, caecum ; 17, vermiform appendix ; 18, ascending colon ; 19, 
hepatic flexure ; 20, transverse colon ; 21, splenic flexure ; 22, descending colon ; 23, sigmoid 
flexure ; 24, bladder. (Rauber.) 

dimensions just given may be greatly altered by pathological con- 
ditions. 

The large intestine differs from the small not only in calibre but 



12 DISEASES OF THE INTESTINES 

also by having three narrow longitudinal bands of unstriped muscle 
fibres (ligamenta or tcenia coli). These begin in the caecum at a 
point corresponding to the insertion of the vermiform appendix. 
Through them the intestine is thrown into numerous sacculi (haustra 
coli), separated from one another by deep folds (sulci transversi). 
These folds and pouches do not exist in the rectum, hence the 
latter is readily distinguished from the other portions of the large 
intestine. 

As regards its course, the large intestine is divisible into 

1. A blind, pouchlike commencement, the ccecum, with the 
vermiform appendix. 

2. An ascending portion, colon ascendens. 

3. A transverse portion, colon transverswn. 

4. A descending portion, colon descendens. 

5. The portion within the left iliac fossa, flexura sigmoidea 
(S. romanum). 

6. The rectum. 

Each of these subdivisions requires separate consideration. 

1. Caecum and Vermiform Appendix 

The blind gut is that portion of the large intestine lying imme- 
diately below the termination of the ileum. Its length is subject to 
wide fluctuations, variously estimated from 4 to 12 centimetres. 
According to Henle, the average length is 5.5 centimetres. Its 
width almost equals its length. The caecum lies in the right iliac 
fossa above the middle of Poupart's ligament, and is in contact 
anteriorly with the abdominal wall. When immoderately long, it 
may extend into the small pelvis. In the majority of cases the 
caecum is completely invested by peritoneum (the mesocaecum). 
This would account for its great freedom of motion and the fre- 
quency with which it forms one of the contents of femoral and 
inguinal hernia. In rare cases the peritoneum is absent from its 
posterior surface. Attached to the anterior surface of the lower 
middle division of the caecum we find the vermiform appendix, an 
organ of extreme practical importance, but of whose physiological 
functions we at present know nothing. It varies in length from 2 
to 20 centimetres ; its width is about -| to 1 centimetre. Usually it 
is spiral-shaped, and is directed from the right iliac fossa toward the 
border of the small pelvis, or it may even dip into the small pelvis. 
It has a small mesentery (mesenterioluwi) and, like the caecum, it 
is freely movable. The appendix is hollow up to its apex, and 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 13 



communicates with the caecum through a small opening, the ostium 
processus vermiformis. This opening is sometimes guarded by a 
small crescentic fold, the valvula processus vermiformis. 

The terminal opening of the small intestine is found at the junc- 
tion of the caecum and ascending colon. This opening, which leads 
from the ileum into the large 
intestine, is guarded by a valve 
formed of two crescentic folds, 
the valvula coli or Bauhini 
(Fig. 9). The two folds, superior 
and inferior, are united at their 
ends, but in the centre form an 
aperture at right angles to the 
long axis of the colon. Normal- 
ly this valve permits the passage 
of contents from the small intes- 
tines into the large, but not con- 
versely. It will not even allow 
the passage of gases insufflated 
into the large intestine. Only 
the combination of extreme 
pressure with a relative insuffi- 
ciency of the valve, such as oc- 
curs in paresis of the intestinal 
wall, can effect a passage of in- 
testinal contents into the ileum. 




Fig. 9. — Opening of the Ileoi into the 
Large Intestine. 
(Perpendicular section through the ccecum 
and ileo-csecal valve.) p. v., vermiform ap- 
pendix, whose opening into the caecum is 
visible. (Gegenbaur.) 



2. Ascending Colon 

The ascending colon passes almost vertically upward from the 
right iliac fossa to the under surface of the liver, upon which latter 
surface it produces the impressio colica. In the region of the gall 
bladder the ascending segment of the colon leaves the posterior ab- 
dominal wall and passes sharply forward and to the left, thus becom- 
ing more superficial ; then, forming the hepatic flexure, the gut 
continues on as the transverse colon. The hepatic flexure of the 
colon is connected with the liver by a short, taut band, the ligamen- 
tum hepatico-colicum. In front, the ascending colon is in relation 
with coils of the small intestines; behind, with the lateral border 
of the quadratus lumborum and with the transversalis abdominis, as 
well as with the lower anterior surface of the right kidney. There- 
fore it is possible to have nephro-colic abscesses without peritonitis. 



14 DISEASES OF THE INTESTINES 

The remainder of the ascending colon is completely surrounded by 
peritoneum. 

3. Transverse Colon 

The transverse colon passes from the right hypochondrium up- 
ward and to the left behind the anterior abdominal wall to the left 
hypochondrium ; then, bending acutely, it continues as the descend- 
ing colon. The angle thus formed is known as the splenic flexure. 
At this flexure the colon leaves its superficial position and passes 
sharply downward and backward. The flexure is connected with 
the diaphragm by the ligamentum jphrenico-colicum. The trans- 
verse colon is provided with a very long mesentery, the mesocolon 
transversum, and is therefore freely movable. This point will 
again be referred to. 

4. Descending Colon 

The descending colon passes from the splenic flexure vertically 
downward through the left hypochondriac and lumbar regions to 
the left iliac fossa, where it forms an S -shaped fold, the sigmoid 
flexure. The splenic flexure is in contact above with the spleen. 
Anteriorly, the descending colon is covered for the most part with 
coils of small intestine. The descending colon, like the ascending, 
has no mesentery of its own, and it therefore is not freely mov- 
able. It is invested only laterally and anteriorly by peritoneum. 
Its posterior surface is in relation with the costal portion of the 
diaphragm, with the left kidney, the trans versalis abdominis and 
quadratus lumborum muscles, as well as with the iliac fascia, to all 
of which structures it is connected by loose connective tissue. 

5. Sigmoid Flexure (S. Romanum) (Fig. 10, page 17) 

This is formed by a double loop of the colon, and has the ap- 
pearance of an inverted S. We may distinguish an upper (colon) 
segment whose convexity is directed toward Poupart's ligament, and 
a lower (rectal) segment which projects more or less into the pelvis. 
As a rule, the transition to rectum occurs at the sacro-iliac synchon- 
drosis. 

The sigmoid flexure is entirely covered by peritoneum, which 
forms a rather long mesentery, the mesocolon flexurce sigmoidece. 
On this account the flexure is freely movable. In the newly born 
the sigmoid flexure has a very long mesentery, and it may therefore 
lie on the right side near the caecum, especially if defecation has 
not yet occurred and the flexure is still filled with meconium. 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 15 

Blood-vessels, Lymphatics, and Nerve Supply of the Large 

Intestine 

The blood supply of the large intestine is derived from the 
three colic vessels, the left colic artery, a branch of the inferior 
mesenteric artery, and the middle and superior colic arteries, 
branches of the superior mesenteric artery. 

The veins , which have a course parallel to that of the arteries, 
empty into the superior and inferior mesenteric veins. 

According to Sappey, the lymphatics of the intestinal wall are 
numerous and form two sets — a deeper, beneath the glands of 
Lieberkiihn, and a more superficial, which forms a network ramify- 
ing in all directions in the submucosa. 

The nerves which supply the caecum, ascending colon, and the 
right half of the transverse colon are derived from the superior 
mesenteric plexus, which is given off by the cceliac plexus. The 
left half of the transverse colon, the descending colon, and the sig- 
moid flexure receive their nerve supply from the inferior mesenteric 
plexus, which in its turn is derived from the plexus of the abdomi- 
nal aorta. 

Histology of the Large Intestine 

The wall of the large intestine, like that of the stomach and 
small intestine, is composed of four layers : serous, mucous, sub- 
mucous 5 and muscular. 

The serous coat has already been considered in speaking of the 
separate segments of the intestine. 

The muscular coat consists of an external longitudinal and an 
internal circular layer. The longitudinal layer is not found through- 
out the entire gut, but appears as three broad longitudinal bands, 
taenia (ligamenti) coli, which are each 10 millimetres in width and 2 
to 3 millimetres in thickness, and are all visible through the serosa. 
Beginning at the attachment of the appendix, they continue as 
separate bands as far as the rectum, where they unite to form a 
continuous muscular layer. 

One of these bands is seen at the attachment of the gastro-colic 
omentum of the transverse colon; at its mesenteric border is a 
second, while the third band is free. Hence they are known as the 
tcenia omentalis, mesenterica and the libera. Between them there 
is a triple row of alternately protruding and receding areas. The 
protruding parts are termed the haustra coli / the depressions, which 



16 DISEASES OF THE INTESTINES 

are parallel to each other and perpendicular to the plane of the wall 
of the gut, are known as the pockets. Wherever haustra and taenia 
cross, we find projections of the serous coat, rich in fat, called ap- 
pendices epiploicce. 

The circular coat extends over the entire colon ; it is strongest 
between the haustra, which it surrounds by folds of considerable 
thickness {plicoe sigmoidece). 

The submucosa is entirely like that of the small intestines. 

The mucous membrane differs from that of the small intestines, 
above all, through the absence of Kerkring's folds and of villi. It 
is thicker than that of the small intestine. The muscularis mucosa, 
a thin layer of crossed muscular fibres, lies beneath the mucosa. 
The glands of Lieberkuhn lend a sievelike appearance to the 
mucous membrane of the large intestine. These glands resemble 
the glands of the small intestine, but are longer and more frequently 
branched than the latter. The mucous membrane between Lieber- 
kuhn's glands contains cylindrical epithelium, goblet cells, and 
numerous solitary lymphatic nodules. 

6. The Rectum 

"We include in the term rectum the lower segment of the large 
intestine from the sigmoid flexure to the anus. The rectum com- 
mences at the sacro-iliac synchondrosis, and therefore lies entirely 
within the pelvis. It varies in length from 18 to 22 centimetres 
(according to other authorities, 25 to 33 centimetres). Its lumen is 
narrower than that of the sigmoid flexure ; immediately above its 
termination there is a normal dilatation, the ampulla recti, which 
even normally varies largely in* size. Contrary to its name, the 
rectum is not straight, but presents curves, three of which can be 
distinguished. Beginning at the sacro-iliac articulation, it at first 
passes slantingly downward and to the right, then runs forward in 
front of the lower portion of the sacrum and coccyx, being (in men) 
behind the bladder, the seminal vesicles, and the prostate, or (in 
women) behind the cervix of the uterus and the vagina. Behind 
the last-named organs (or the prostate) the rectum again curves 
downward and backward and terminates at the anus. 

For practical purposes we distinguish between the rectum proper 
and the anal portion — i. e., the part surrounded by the sphincter 
ani. 

The upper portion only of the rectum is covered by peritoneum, 
the mesorectum, a direct continuation of the mesocolon sigmoidea. 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 17 

Like the sigmoid, the upper portion of the rectum has also some 
range of motion. Farther down, the peritoneum recedes from the 
rectum and is reflected on to the bladder in the male, or on to the 




Fig. 10. — Male Pelvic Organs, viewed from the Eight Side ( x y 3 ). 
(The right ilium and a portion of the ischium and the pubic bone, together with their 
soft parts, have been removed.) 1, auricular surface of the sacrum; 2, tuberosity of the 
sacrum; 3, ischium; 4i pubic bone; 5, psoas muscle; 6, erector spinae ; 7, glutei muscles; 8, 
obturator muscles ; 9, external sphincter of anus ; 10, rectum ; 11, sigmoid flexure ; 12, blad- 
der ; IS, ureter ; 14, vas deferens ; 15, seminal vesicles ; 16, prostate ; 17, penis ; 18, prepuce ; 
19, scrotum ; 20, lateral vesical ligament ; 21, hypogastric artery ; 22, hypogastric vein ; 23, 
external iliac artery; 24, abdominal aorta. (Eauber.) 



vaginal vault and uterus in the female. Above the point of reflec- 
tion two crescentic folds, inclosing smooth muscle fibres, pass from 
the sideg of the rectum to the bladder or to the uterus (the folds of 



18 DISEASES OF THE INTESTINES 

Douglas). The space beneath these folds is known as the recto- 
vaginal,soid the one above as the recto-vesical, pouch. 

The relative position of these peritoneal folds is not constant, 
however, but varies according to age and sex, as well as to special 
conditions of the neighboring organs. The above subdivision is 
therefore of an anatomical rather than a practical value (von Es- 
march). 

The muscular coat of the rectum consists of an inner circu- 
lar and an outer longitudinal layer. The circular layer, which is 
directly continuous with that of the colon, constantly increases in 
thickness toward the lower end of the gut, finally forming a ring 
1 or 2 centimetres in length, the internal sphincter of the anus. 
The externa], the longitudinal, layer is continuous with the three 
longitudinal bands of the colon. In the rectum it forms a uniform 
layer, interrupted here and there by small intervals. The fibres 
become thinner in the lower part of the rectum, and finally merge 
with those of the external sphincter. 

Contrasted with the feeble muscular coat of the upper portion 
of the rectum, the anal portion contains two powerful bands of cir- 
cular fibres which secure closure of the anus. They are the exter- 
nal and internal sphincters {sphincter ani externus et internus). 

The external sphincter, whose action is voluntary, arises by a 
tendinous origin from the apex of the coccyx, and separates into 
two divisions which surround the anal orifice. In front of the anus 
it is connected, in the male, with the musculus bulbo-cavernosus, or 
transversus perinei, and in the female with the constrictor cunni. 

The internal sphincter of the anus, a ring or girdle of smooth 
muscle fibres, is the direct prolongation of the circular layer of the 
rectum ; these fibres gradually increase in strength as they approach 
the anus. Connected with the internal sphincter are two muscular 
fasciculi, 4 millimetres in width, which spring from the anterior 
surface of the coccyx and surround the lower end of the rectum (the 
musculi recti-coccygei). 

A short distance below the middle of the rectum (about 8 centimetres above 
the anal orifice) we sometimes find a prominent collection of circular fibres, to 
which the name " sphincter ani tertius" has been given (Hyrtl). This "sphinc- 
ter," however, is nothing more than the transverse rectal fold increased by some 
circular fibres. 

The mucous membrane of the rectum is thicker, redder, and 
more succulent than that of the colon. It presents many folds, 
varying in size and directions, and disappearing when the organ is 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 19 

strongly distended. They are most distinct when the rectum is 
empty. One deep, transverse fold alone does not disappear even 
with the greatest possible distention of the rectum. This fold — the 
plica transversalis recti — is about 6 to 8 centimetres above the 
anus, and can be distinctly seen through a speculum. It is a sickle- 
shaped reduplication of the mucous membrane, and does not include 
the entire circumference of the rectum. Xear the anal opening 
the folds are usually longitudinal, and have received the name of 
rectal or columns of Morgagni. The pockets between the folds are 
known as sinuses of Morgagni • they are favourite lodging places 
for intestinal parasites and for swallowed pointed foreign bodies. 
The mucous membrane covering these folds and pockets differs 
from that of the rest of the rectum by the absence of glands and by 
the presence of moderate-sized papillae, partly agminated. The 
epithelium is stratified, and consists of large pavement cells. Thus, 
the lower portion of the rectum forms a transition from mucous 
membrane of the intestinal canal to skin (Henle). The mucous 
membrane of the upper portion of the rectum differs in no respect 
from that of the remainder of the large intestine. 

The rectum receives its blood from five arteries, branches of 
three arterial trunks. The largest of these five, the superior haem- 
orrhoidal artery, is given off by the inferior mesenteric ; the middle 
hemorrhoidal arteries, two in number, come either from the hypo- 
gastric or from the common pudendal ; the two smallest vessels, the 
inferior hemorrhoidal arteries, come from the common pudendal. 

The blood is carried away from the rectum for the most part 
by the portal system through the superior hemorrhoidal vein, and 
the remainder by the middle and external hemorrhoidal veins, 
which empty into the inferior vena cava. 

The lymphatics form an extensive network with wide meshes, 
which sends some branches to the retrorectal glands and others to 
the left lumbar plexus. 

The nerves are derived mainly from the sympathetic. They 
come from the inferior mesenteric plexus, the sacral plexus (inferior 
and middle hemorrhoidal nerves), and from the superior hypogastric 
plexus. 



DISEASES OF THE INTESTINES 



APPENDIX 



Displacements of the Various Segments of the Intestines 

As a consequence of congenital or acquired anomalies, the va- 
rious segments of the intestines may undergo alteration in posi- 
tion. These displacements are very important for the diagnos- 
tician, and in order to prevent serious error it is necessary that he 
be acquainted with or at least consider them. The portions most 
frequently affected are the duodenum and the entire large intes- 
tine, exclusive of the rectum ; much less frequently, and usually as 
a consequence of the above anomalies, the remainder of the small 
intestine. 

The superior horizontal portion of the duodenum is so closely 
connected with the stomach that it would naturally be affected by 
alterations in position of that organ.* Should the stomach be 
pushed toward the left side, the superior horizontal portion of the 
duodenum would be on a line with the pylorus. If the pylorus be 
dragged to the left of the median line of the body, the first portion 
of the duodenum will then lie upon the vertebral column. Should 
the pylorus be within the median line or to the right thereof, the 
same portion of the duodenum will curve around the vertebral col- 
umn (Hertz). The gut thus becomes more superficial, and the 
superior flexure of the duodenum is bent almost at a right angle. 
Where there is a fish-hook-shaped ptosis of the stomach, the first 
portion of the duodenum will also be drawn downward, and will 
assume an almost vertical position. A sharp bend is thus given to 
the flexure, and it may be so pronounced as to even cause a partial 
obstruction of the contents. Again, where the stomach in toto is 
sunken, it will drag the first portion of the duodenum, or even the 
entire duodenum, down with it. Under other conditions the duo- 
denum can preserve its normal position. 

The descending portion of the duodenum is less freely movable, 
because of its close connection with the pancreas. Despite this, 
both organs may be simultaneously displaced. Braune observed a 
case in which this portion of the duodenum was dislocated to the 
left. Displacement of other organs, especially of the stomach, the 
liver, transverse colon, etc., naturally causes displacement of the 

* See Hertz. Abnorinitaten in der Lage und Form der Bauchorgane, etc., 
Berlin, 1894, S. 33. 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 21 

duodenum as well. Nevertheless, the tendency of the descending 
portion to become dislocated is limited. 

The inferior horizontal portion is subject to slight alterations in 
position alone, and these are brought about by the same conditions 
as those of the remainder of the duodenum. We wish here to call 
attention to the large number of adhesions which occur in the region 
of the gall bladder and the duodenum, and which may create great 
difficulties in diagnosis as well as in treatment. 

Alterations in position of the colon are most common. Cursch- 
mann 1 has recently called attention to their clinical importance. 
The following statements are taken largely from Curschmann's 
excellent treatise. 

1. The Cjectjm and the Ascending Colon 

The caecum may be abnormally long, and thus give rise to vol- 
vuli, kinking, and flexures. In such cases the fundus of the caecum 
is directed toward the diaphragm, and covers a part of the ascend- 
ing colon. Thus we may at times have a total occlusion of the 
gut. It should be remembered that such a dislocated caecum, to- 
gether with the appendix, may be the seat of a perityphlitis. 

In those very rare cases in which the ascending colon is con- 
genially entirely absent, the caecum with its appendix lies very 
close to the edge of the liver, or behind that organ. Perityphlitis 
has been observed under such conditions, but the clinical diagnosis 
is very difficult, if not impossible. 

2. The Teansveese Colon and the Flexuees 

It is a well-known fact that the transverse colon [especially in 
the female] is subject to the greatest variations in position. This is 
probably due to the habit of lacing, through which one portion of 
the abdominal contents is forced upward and the other downward. 
When its mesentery is excessive in length, the transverse colon may 
be dislocated upward and lie in the epigastrium in front of the 
liver, or in the left hypochondrium in front of the stomach (Hertz). 
In other cases, the transverse colon may be entirely concealed by 
coils of small intestine ; we then find it low down in the posterior 
portion of the abdomen (Hertz). 

Absence or shortening of the flexures may give rise to condi- 
tions of special interest. For example, the colon may pass from 
the right side upward and toward the median line ; thence trans- 
versely for a short distance ; then, abruptly bending to the left, con- 
3 



22 DISEASES OF THE INTESTINES 

tinue downward as the descending colon. Again, in a very long 
colon, both flexures may be shortened or absent. The transverse 
colon in such cases forms a large loop, whose segments lie close to 
each other and in direct contact with the liver, and may cover the 
entire anterior surface of that organ. Here we would get apparent 
diminution in liver dulness in front, but percussion of the lateral 
and posterior surfaces should save us from mistakes. 

Marked increase in length of the large intestine may give rise 
to the coiling together of the intestines, or even to the formation 
of a volvulus. 

3. The Descending Colon and the Sigmoid Flexure 

The sigmoid flexure is the most movable segment of the large 
intestine, because its length is subject to the greatest variations. 
Its displacements, as well as those of the descending colon, have 
been noted by the older anatomists. Kecently Schiefferdecker 2 
and von Samson 3 have made a close study of the subject. 

Schiefferdecker distinguishes the following alterations in position of the 
descending colon: 

I. The end of the descending colon lies to the side of the sigmoid flexure. 

(a) The flexure projects into the small pelvis, and the small intestines lie in 
front and above it. 

(5) The flexure lies upon the posterior abdominal wall, and is directed up- 
ward ; a, it lies within the left half of the body ; /3, it extends to the right iliac 
fossa. Between these extreme left and right positions the greatest variations 
occur. 

(c) Other portions of the intestines separate the sigmoid flexure from the 
posterior abdominal wall, with the result that a greater or lesser portion of that 
gut lies directly behind the anterior abdominal wall. These variations can 
only occur with a free mesosigmoideum, and the higher the lateral point of 
fixation of the sigmoideum, the greater will be the predisposition to these dis- 
placements and their extent upward. The apex of the sigmoid flexure may 
move from the extreme left side of the body to the extreme right. 

II. The termination of the descending colon lies to the median side of the 
sigmoid flexure. This is extremely rare. 

Curschmann, who has given special attention to the clinical im- 
portance of the anomalies of the sigmoid flexure, lays particular 
stress upon the striking differences in its length (60 to 80, or even 
100 centimetres). Sometimes there are two coils instead of one. 
A more frequent anomaly is the formation of an abnormal loop be- 
tween the lower end of the sigmoid and the beginning of the rectum. 
In such cases we almost always find the lower end of the colon far 



PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 23 

down in the pelvis and over to the right side. Under such circum- 
stances, the commencement and termination of the large intestine 
lie side by side. It is very apparent how gross errors in diagnosis 
may occur. This has been very aptly illustrated in one of Cursch- 
mann's cases. The position of the coils of the sigmoid may also be 
greatly altered. Normally, they are in the centre of the abdomen, 
their long axis being parallel with the linea alba. The upper bor- 
der is in contact with the transverse colon. With increase of 
length the coils may even reach the vault of the diaphragm, and 
completely cover the stomach and liver. This abnormality in posi- 
tion may make it difficult to determine the limits of the liver and 
stomach. It appears that almost invariably the base of the coils is 
covered by small intestine. If volvulus should occur in these 
cases, we should then find tympanitic intestinal coils at all points, 
excepting the one at which the volvulus is situated — i. e., the region 
of the sigmoid flexure. 

LITERATURE 

1. Curschmann. Deutsch. Archiv fur klin. Medicin, Bd. liii, H. 1 u. 2. 

2. Schiefferdecker. Archiv flir Anatomie u. Physiologie, 1886 u. 1887. 

3. v. Samson. Zur Kenntniss der Flexura sigmoidea coli. Inaug. -Dissert., 

Dorpat, 1890. (Complete literature.) 



CHAPTER II 

INTRODUCTORY PHYSIOLOGICAL AXD PHYSIOLOGICO- 
CHEMICAL REMARKS 

The digestive process in the intestines is far more complicated 
than in the stomach. In the latter the digestive act is but a pre- 
paratory one, affecting only the proteid bodies (and gelatinoid sub- 
stances) and the starches. Absorption, as we now know, takes 
place but to a limited extent (v. Mering, Brandl, Moritz, Hirsch, 
and others). The digestive task of the intestines consists princi- 
pally in converting all food stuffs, brought to it from the stomach, 
into a form suitable for assimilation ; in absorbing the useful por- 
tions, and gathering together in a solid form and excreting from 
the body all waste material. The intestines, however, have another 
function, heretofore but little appreciated by physiologists and clini- 
cians — i. e., the removal in the form of flatus of noxious gases devel- 
oped in the intestinal canal. This might be termed intestinal ven- 
tilation. 

All the functions of the intestines harmonize like the component 
parts of a score ; interference with one deranges all. Strictly speak- 
ing, then, these functions should not be considered separately. If, 
nevertheless, we do so in the following, it is because the entire pro- 
cess of digestion — the influence exerted by a single function upon 
the whole, and vice versa — is not well enough understood either in 
man or in the lower animals. 

In the following we shall first treat separately of intestinal secre- 
tion, absorption, and motility, and then of the entire course of intes- 
tinal digestion. As by-products of intestinal activity, we have cer- 
tain fermentation substances, some useful, others harmful. They 
also will be considered in the section on intestinal digestion in its 
entirety (page 43). 

THE SECRETING FUNCTION OF THE INTESTINES 

The secretion furnished by the intestines themselves plays but 
an insignificant part in the digestive process. The main work is 
24 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 25 

accomplished by the secretions from the two glands emptying into 
the small intestine, viz., the liver and the pancreas. 

1. The Intestinal Juice 

This is a mixture of secretions from Brunner's and from Lieber- 
kuhn's glands. Griitzner 1 ascribes the faculty of secreting pepsin 
to Brunner's glands ; this would give them functions analogous to 
those of the pyloric glands. They certainly do not secrete any 
diastatic ferment. Other investigators regard Brunner's simply as 
mucous or salivary glands. 

Our information regarding the secretion of Lieberkuhn's glands 
is more definite, for this has been studied in animals by the aid of 
the Thiry or Vella fistula, and also in individuals with faecal fistulse 
(Dumont, Turby and Manning). Observations thus made showed 
the secretion to be pale yellow in colour, highly albuminous and muci- 
form, and containing about 0.5 per cent, of sodium chlorid and a 
like amount of sodium carbonate. Hoppe-Seyler 2 lays special value 
upon this mucosity, since mucin forms a protective coating for the 
intestinal epithelium, and makes possible as well as facilitates the 
passage of the solid masses within the intestines. 

Another very important factor is the presence of the carbonate 
of soda. This affects the rapid neutralization of the acid stomach 
chyme. Bunge, 3 in fact, ascribes the importance of the intestinal 
secretion mainly to its carbonate of soda.* 

In dogs, the solids of the intestinal juice equal 12.2 to 24.1 
grams per 1,000 ; in sheep, 46 to 47 grams. According to Thiry, 
the specific gravity of the secretion varies in dogs from 1010 to 
1017. 

It is generally conceded that the fermentative action of the in- 
testinal juice is very slight. It has been shown that starch after a 
long time is converted into glucose, and cane sugar is inverted 
through the action of the intestinal secretion (Demant 4 , Brown and 
Heron 5 , K. B. Lehmann 6 , Frick, Turby and Manning 7 , and Miura 8 ). 
Similarly F. Rohmann and Lappe 9 have found that an extract of 
mucous membrane from the small intestine of the calf or dog can 
convert milk sugar into glucose. The secretion from Lieberkuhn's 
glands has no action whatever upon albuminoid bodies and fats 



* In diseased conditions, marked odourless eructations may occur some time after 
eating. It appears very probable to me that this results from decomposition of the 
hydrochloric acid of the stomach by the alkaline intestinal secretion. 



26 DISEASES OF THE INTESTINES 

(Frick 10 , Ellenberger and Hof meister n , K. B. Lehmann 6 , Wenz 12 , 
and others). The secretion from Lieberkuhn's glands in the large 
intestine appears to be mostly mncous. 

2. The Pancreatic Juice 

The action of the pancreatic secretion has been studied princi- 
pally upon animals in whom fistulse have been made. A few 
observations have been made with the secretion from fistulse fol- 
lowing the extirpation of pancreatic tumours, particularly cysts. 
I have myself made a few such observations. The credit for 
most of our knowledge of the function of the pancreas is due 
to CI. Bernard, C. Ludwig, Bidder and Schmidt, Heidenhain and 
Bernstein. The fundamental studies of v. Mering and Minkowski 
first brought out the importance of the pancreas in diabetes. 

In experiments upon animals two varieties of fistulas, the temporary and 
the permanent, are employed. If a fistula be made in a dog after a hearty 
meal, the secretion which flows will be profuse, viscid, and very active. Activ- 
ity ceases, however, after a few days — sometimes after a few hours — and it is 
succeeded by a thin, watery, inert secretion, very poor in albuminoids, and 
resulting very probably from inflammatory changes. In a few cases it has 
been possible to obtain an active secretion from a permanent fistula. It is 
therefore easily understood that analyses of the secretion vary very much. 

The normal secretion of the pancreas is a clear, colourless, and 
odourless, viscid fluid, of a strongly alkaline reaction. The alka- 
linity is due to sodium carbonate which is present in from 0.2 
to 0.4 per cent. The secretion is highly albuminous and coagu- 
lates strongly upon boiling. In addition to the above, it contains 
leucin, fats, fatty soaps, and the following mineral ingredients : 
Alkaline chlorids and carbonates, phosphoric acid, and some cal- 
cium, magnesium, and iron. 

In the secretion from a temporary fistula of a dog, C. Schmidt 13 
once found 9.92 per cent of solids, and at another time 11.56 per 
cent ; while Zawadsky 14 , in examination of pancreas fistula of a 
man, found 13.25 per cent of solids, of which 9.2 per cent were 
proteids and 0.34 per cent mineral substances. Herter 15 found 
24.1 per cent solids in the secretion of a man; this secretion, 
though very active, seems to have been pathological in other 
respects. From the above analyses, we may regard 10 per cent as 
the average amount of solid matter. 

The most important pancreatic ferments are the proteolytic, the 
amylolytic, and the fat- splitting. 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 27 

(a) At the proper temperature the proteolytic ferment, trypsin 
(Kiihne), is capable of converting proteids in a very short time into 
albumoses and peptones. This ferment does not exist preformed 
within the gland, but is there instead as trypsin ogen (Heidenhain 
and Podolinski 16 ). Trypsinogen is changed into trypsin through 
bacterial influences, contact with air or water, or with dilute acids 
(e. g., 1 per cent acetic acid). Trypsin is most active in a 0.2- or 
0.4-per-cent solution and at 40° C. Small amounts even of free 
mineral acids retard its action, but organic acids must be present in 
stronger concentration. The kind of albuminous matter is not 
without influence. Thus, as in gastric juice, fibrin is digested 
much quicker than is coagulated egg albumen. 

The initial stage of proteid digestion with trypsin differs very 
much from that with the gastric juice. Whereas in the latter 
there is a preliminary swelling of the albuminoid substance fol- 
lowed by gradual solution, in trypsin digestion there is a breaking 
up, or, more properly speaking, a melting away. 

As in the stomach, so, too, in trypsin digestion the metamor- 
phosis of the albuminoids is not a sudden but a gradual one. 
According to Kiihne, who has studied the proteolysis of trypsin 
digestion more carefully than any one else, the albuminoids are 
first converted into deutero - albumoses, but after a very short 
time peptones are also present. One portion of these peptones — 
Kuhne's antipeptones — remains unchanged throughout the entire 
digestion, even though this may continue for several days, while 
another portion — Kuhne's hemipeptones — yields products of decom- 
position, the most important of which are the crystalline amido- 
acids — leucin, tyrosin, and aspartic acids. These latter products 
have been well known for a long time ; of late, E. Drechsel and 
Hedin 17 have succeeded in isolating two additional products of 
trypsin digestion, lysin and lysatinin. Finally, a chromogen, tryp- 
tophan, is regularly formed during tryptic action upon albumi- 
noids 18 . With bromin or chlorin water, or with chlorate of potash 
solution, tryptophan yields a violet colouring matter, readily absorbed 
by amylic alcohol. 

Trypsin also acts upon the gelatins, causing them to lose their 
gelatinous qualities and to be converted into gelatin peptones. 
Kuhne's and Koberts's 19 investigations with the trypsin of pigs' 
pancreas have shown that this ferment curdles milk. My own 
investigations 20 have proved that milk is not curdled by the biliary 
juice contained in the duodenum (a mixture of bile, pancreatic 



28 DISEASES OF THE INTESTINES 

juice, and the secretions of Branner's and Lieberkiihn's glands), 
but that it is immediately peptonized. If the gelatin-yielding sub- 
stance of connective tissue is previously swelled by the action of 
acids, or shrunken through the agency of heat, it will be dissolved. 
Elastic membranes, as well as the membranes of fat globules, are 
immediately dissolved. Chitin and keratin apparently are not 
dissolved by trypsin. 

(J>) Pancreatic Diastase. — This ferment has the property of 
converting starch and glycogen into sugar, the end products being 
mostly maltose, together with small quantities of dextrose (Muscu- 
lus and Gruber 21 and v. Mering 22 ). This conversion is a hydration 
process, and the intermediate products are the same as those occur- 
ring in the diastatic action of ptyalin, with which ferment pancreas 
diastase is in all probability identical. Taken in their order of 
occurrence these intermediate products are : first, soluble* starch, 
which still gives a blue colour with Lugol's solution of iodin ; next, 
erythrodextrin, which gives a violet colour; and, finally, one or 
more of the achroodextrins, which remain uncoloured upon addition 
of Lugol's solution. 

In addition to diastase, pancreatic juice also contains invertin, 
although in much smaller quantities than does the intestinal secre- 
tion. It is assumed that this ferment gradually completely con- 
verts maltose into dextrose (glucose). In like manner cane sugar 
and milk sugar are also converted into glucose by invertin. Glyco- 
gen is first converted into a maltoselike sugar, and then gradually 
also changed into glucose. 

(e) The Fat- splitting Ferment (Steapsin). — This ferment splits 
up fats into fatty acids and glycerin. In the presence of alkalies 
these fatty acids combine to form soaps ; furthermore, they aid 
very much in the emulsification of fats. We shall return to this 
when we come to speak of bile. Steapsin has not yet been iso- 
lated, and the attempt has therefore been made to refer the split- 
ting up of fats in the intestines to the action of bacteria. The 
researches of Nencki 23 have, however, shown the positive existence 
of a fat-splitting ferment in pancreatic juice. In my own investi- 
gations M with the small intestinal juices of man I have observed 
marked fermentative dissolution of fat. 

According to Nencki and Baas 25 , pancreatic ferment decom- 
poses other esters besides the neutral fats. We shall speak of the 
part played by the pancreatic juice during digestion when discuss- 
ing intestinal digestion in its entirety. 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 29 

3. The Bile 

The importance of the bile in digestion was formerly very 
much overestimated. At the present day bile may be looked upon 
as possessing more of an excretory than a secretory importance, 
since it has to render innocuous the products of body metabolism 
stored up in the liver and safely conduct them from the body by 
way of the intestines. It would be going too far, however, to 
assign but this one function to the bile. Without doubt it has an 
important part in intestinal digestion, especially in regard to the 
fats. This will be referred to again later. 

The composition of bile varies with different animals ; that of 
the dead body is different from that of the living, and that flowing 
from the biliary passages is not the same as that contained within 
the gall bladder. 

Human bile, such as is obtained immediately after death from 
executed persons, is usually of a golden-yellow colour with a shade 
of brown. Greenish-coloured bile has also been seen, especially 
during operations. Bile such as I have seen regurgitated into the 
stomach in numerous cases of deeply situated duodenal stenoses was 
almost always green ; in a very few cases where there was a normal 
condition of the duodenum, I saw bile of a golden-yellow colour. 
The taste of bile varies in different animals ; that of man and of 
cattle is bitter and has a sweetish after taste, while that of the rab- 
bit and the pig has a purely bitter taste. The specific gravity of 
that in the gall bladder varies from 1001 to 1004. The reaction is 
faintly alkaline, due to the presence of the carbonate of soda (.02 
per cent) and of alkaline sodium phosphate. The amount of solids 
in bile obtained from fistulse varies so largely that figures are value- 
less. This holds true, too, for the total quantity in twenty -four 
hours of bile from fistulge, for an appreciable but immeasurable 
portion must flow into the small intestine itself. Besides, as Stadel- 
mann has correctly shown, marked variations in the biliary secre- 
tion may occur under normal conditions. Bile contains very much 
mucin as well as mucoid nucleo -albumin. 

The most important constituents of bile are the two biliary acids 
and their salts — the glycocholate of soda and the taurocholate of 
soda — cholesterin, and a number of biliary colouring matters. In 
addition there are small quantities of lecithin, neutral fats, soaps, 
urea, and mineral salts. 

As regards the two biliary acids, it should be stated that glyco- 






30 DISEASES OF THE INTESTINES 

cholic acid (C 2 6H4frN~0 6 ), which is combined with sodium and traces 
of potassium, is more abundant in man ; while taurocholic acid 
(C 2 6H 45 NS0 7 ) is found in carnivora and in goats and sheep. As 
can be seen from the formula, taurocholic acid contains both nitro- 
gen and sulphur, whereas neither of these substances is present in 
glycocholic acid. Both acids have a bitter taste and are dextro- 
gyrous ; they are decomposed upon boiling with caustic potash, 
glycocholic acid splitting up into glycin and cholic acid, and tauro- 
cholic acid into taurin and cholic acid. 

The biliary colouring matters met with under normal conditions 
are bilirubin (reddish yellow) and biliverdin (green), and one col- 
ouring substance closely related to hydrobilirubin (urobilin). 

Bilirubin (identical with hsematoidin) is found in the golden- 
yellow bile of man, and is present to a marked degree in biliary 
concretions as bilirubin-calcium. It is insoluble in water, sparingly 
soluble in ether, a little more so in alcohol, and readily in chloro- 
form, especially if warmed. Upon evaporation it may be obtained 
partially in crystalline form, partially as an amorphous substance. 
Solutions of bilirubin in chloroform yield reddish-yellow rhombic 
scales which are exactly like hsematoidin. For other properties of 
bilirubin, as well as for its chemical reactions, we refer the reader 
to works on chemical physiology. 

Biliverdin results from oxidation of bilirubin, and is met with 
in the bile of man, of the lower animals, and also in the urine of 
jaundice, and to a less extent, too, in gallstones. It is an amor- 
phous substance readily soluble in alcohol, sparingly in ether, and 
insoluble in chloroform, thus differing widely from bilirubin. 

Hydrobilirubin results from the reduction of bilirubin, and is 
constantly present as colouring matter in normal faeces. It is in all 
probability identical with urobilin and the so-called stercobilin. 

Cholesterin is held in solution by the bile salts. It crystallizes 
in colourless rhombic plates, is insoluble in water, but soluble in 
hot alcohol, in ether and chloroform. 

It is claimed that in addition to the above-described constituents, 
there is also a diastatic ferment present in bile ; but very probably 
it is the diastase of the salivary and intestinal secretions. 

Importance of Bile in Intestinal Digestion. — Apparently the 
principal function of the bile is to promote the absorption of fat. 
This is readily seen from the fact that dogs with biliary fistulae 
absorb far less fat than do normal animals. Whereas a normal 
dog, according to Yoit 26 7 given 150 to 250 grams of fat will absorb 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 31 

99 per cent of it, one with a biliary fistula given 100 to 150 grams 
can absorb but 40 per cent, the remaining 60 per cent passing off 
with the fasces. Rohmann 27 arrived at similar conclusions. On the 
other hand, it may be stated as an actual fact that no disturbance of 
digestion occurs when the bile is conducted externally, provided, 
however, that the amount of fat partaken of be not too large.* 
There is still much doubt as to the manner in which bile promotes 
fat absorption. We know that it favours the emulsification of fats. 
This action, according to Neumeister 28 , results from its cholates, 
which dissolve the potassium and magnesium soaps that are insol- 
uble in the other fluids of the small intestine. According to the 
more recent views of physiologists, especially those of Heidenhain ^ 
bile promotes the entrance of fat into the epithelial cells by favour- 
ing fat emulsification, and by imparting to the surface of the cells a 
capillarity toward fat. Further characteristics ascribed to bile are 
antiputrefactive qualities and stimulation of intestinal motions (dogs 
with biliary fistulas and human beings with occlusion of the bile 
passages are obstinately constipated). f The latter results from the 
free bile acids which normally are always present in the small intes- 
tine. The fasces of dogs with biliary fistulas have a most decided 
stench, resulting from the decomposition of carbohydrates. Bile 
has no digestive action upon albuminoid bodies. 

INTESTINAL PERISTALSIS 

{Motus peristalticus) 

The object of intestinal peristalsis is to secure a mingling of the 
contents and their onward propulsion. Thus not only is the pabu- 
lum brought into intimate contact with the digestive juices, but as 
soon as this is accomplished the contents are further conducted 
through successive portions of the intestines, and thereby thorough 
absorption is secured. From this it follows that the small intestines 
are mostly concerned with peristalsis, and that peristalsis takes place 
almost exclusively during the act of digestion. 

* Compare, for example, Mayo Robson, Proc. Roy. Soc, vol. xlvii, 1890, pp. 
499-524 ; Copemann and Winston, Jour, of Physiology, vol. x, 1889, pp. 213-231 ; 
Noel Paton and John Balfour, Laboratory Reports issued by the Royal College of 
Physicians, Edinburgh, 1891, vol. iii, pp. 191-240 (cited from Gamgee, Physiolog- 
ische Chemie der Verdauung, 1897, p. 288). 

f As far as man is concerned, I can not, in general, personally confirm this rule, 
which we find laid down with the greatest certainty in almost all text-books on 
physiology. 



32 DISEASES OF THE INTESTINES 

The excellent investigations of Braam-Houkgeest " of Sanders- 
Ezn, and of ISTothnagel 31 , who studied peristaltic movements in ani- 
mals placed in physiological salt solution, have acquainted us fully 
with all the details. We may distinguish three types of normal 
intestinal movements : peristalsis proper, pendulum motion, and 
rolling motion. 

1. In peristalsis proper there is a widening of the lumen of the 
gut, followed by a narrowing — a wavelike motion, which passes with 
moderate speed over a certain length of intestine toward the anus, 
and thereby causes a visible onward propulsion of intestinal con- 
tents. In the colon the peristaltic wave is represented by depres- 
sions and prominences of the haustra following each other in regu- 
lar succession. 

2. Pendular motions are always limited to a short portion of the 
gut. In these the gut is moved to and fro without any perceptible 
change in the width of its lumen. There is no propulsion of the 
contents, but, instead, a mingling of the same. Propulsion takes 
place only where peristalsis is associated with pendular motions, a 
combination which has been observed. According to Nothnagel, 
pendular motions may be seen particularly in the middle and lower 
segments of the intestines when these are filled with pabulum. The 
motions may last as long as fifteen minutes, when they suddenly 
cease, to begin again after a long time (one hour to an hour and a 
half) without any special cause. This period of cessation is said to 
be shorter in the lower portion of the ileum only. Braam-Houk- 
geest observed pendular motion in empty as well as filled intestines ; 
Nothnagel in the latter only. 

3. Rolling motions occur where a segment of the gut is strongly 
distended by gas and at the same time has fluid contents. Such a 
segment is from 10 to 20 centimetres long. Its contents are pro- 
pelled with a rapidity closely resembling a condition known as 
violent peristalsis. The following is Nothnagel's classical descrip- 
tion : 

" A circular constriction constantly progresses behind the dis- 
tended intestinal coils, causing such a propulsion of the fluid and 
gaseous contents toward the caecum that the widely distended in- 
testinal parts roll about like a wheel quickly revolving in water. 
And now a surprising occurrence is often observed : without the 
slightest external cause, the peristalsis may suddenly cease at any 
segment whatever, to begin very strongly again after an indefinite 
interval." 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 33 

An analogy to these movements is furnished ns by the familiar 
violent peristalsis {tormina intestinorum) often experienced very 
soon after a serious dietetic error. But, as Nothnagel distinctly em- 
phasizes, these movements do not involve the entire length of the 
small intestine ; they completely cease after rapidly passing along a 
limited portion, and suddenly and without apparent cause begin 
anew in another portion. They are most active in the duodenum 
and jejunum ; movements in the duodenum being excited by the 
bile and pancreatic secretion. Farther down in the small intestine 
the peristaltic waves are less frequent and slower. 

In consequence of the peristaltic action of the small intestine, 
the pabulum from a large meal passes in from two and a half to 
three hours from the pylorus to the ileocecal valve ; whereas, owing 
to slowness of peristalsis in the large intestines, food requires at 
least twelve hours to pass through the much shorter distance be- 
tween the caecum and the rectum. 

According to investigations of Braam-Houkgeest, which have 
been fully verified by Nothnagel, peristaltic movements in normal 
intestine with free lumen proceed always toward the anus and never 
toward the pylorus. Nothnagel therefore rejects the occurrence 
of antiperistalsis, such as has been described by older investigators, 
particularly Engelmann, as taking place physiologically. There 
appeared, however, to be two exceptions : When Nothnagel intro- 
duced active irritative fluids (e. g., concentrated solutions of sodium 
chlorid, of potassium nitrate or bromate, or weak solutions of sul- 
phate of copper) into the rectum of rabbits, he observed antiperi- 
staltic movements as far as the caecum, but these movements could 
be induced from the rectum alone ; they were never evoked by irri- 
tative solutions of salt introduced through the stomach. Even after 
artificially produced acute intestinal obstruction in animals, JN r oth- 
nagel did not observe antiperistalsis. There was, indeed, a backward 
movement of the intestinal contents ; this resulted, however, not 
from antiperistalsis, but rather from a procedure which Nothnagel 
has designated " recoil contraction." In consequence of the lively 
peristalsis and of the increase in intestinal secretions above the 
stenosis, there is a large accumulation of the contents in the supra- 
stenotic part. As the wall of the gut becomes distended, the por- 
tion immediately above the stenosis contracts strongly; this may 
result in forcing the contents upward. Nothnagel does not believe 
that the regurgitation of intestinal contents in intestinal obstruction 
is brought about in this manner, but maintains that it results from 



34 DISEASES OF THE INTESTINES 

pressure of the abdomen upon the distended paretic wall of intes- 
tines above the stenosis. 

The above-mentioned investigations of Nothnagel show that no 
backward peristaltic waves can be observed in the physiologically 
functionating intestine. 

A different condition can be observed when we employ mild 
irritants, such as injections of normal salt solution, which to a cer- 
tain extent are still physiological. Thus Griitzner 32 has lately 
called attention to the interesting fact that the injection of physio- 
logical salt solution into the rectum of man and the lower animals 
produces antiperistaltic movements, which involve not only a short 
segment, but also the entire intestine up to the duodenum ; further- 
more, Griitzner showed hereby that small solid particles (starch 
granules, hairs, charcoal, etc.) which are suspended in the injected 
fluids are carried up to the duodenum, or even in part to the stom- 
ach, being found in the wash water from the latter organ. 

Simultaneously with these antiperistaltic movements, which 
pass immediately next to the mucous membrane, there also occur 
peristaltic movements by which faeces and chyme are brought down- 
ward. 

Thus far control examinations by others do not entirely confirm 
Griitzner's conclusions. Christomanos 33 , Dauber 34 , and Wendt 35 
think positive results were obtained because the animals licked 
their own intestinal evacuations ; where this was carefully guarded 
against, negative results were obtained. By experiments upon 
human subjects, Swiezynski 36 was able to demonstrate that lycopo- 
dium introduced into the rectum passed upward into the stomach. 
He, however, was unable to determine with certainty the part which 
sodium chlorid played in this experiment. Be this as it may, the 
investigations of Griitzner do not prove the occurrence of a true 
antiperistalsis, but only show that food stuffs introduced into the 
rectum may pass upward within the intestine. We fully coincide 
with Biegel 37 , who regards the superficial epithelium of the intes- 
tines as the chief causative factor in this upward movement. 

Wherein lies the impulse for intestinal movements ? Investiga- 
tions made thus far upon this point show that the intestinal wall has 
automatic movement centres similar to those of the heart, and, 
furthermore, that the central nervous system exerts an important 
influence upon physiological and pathological intestinal movements. 
The principal seat of the automatic centres is very probably the 
nerve and ganglion plexuses of Meissner and of Auerbach. Noth- 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 35 

nagel could elicit intestinal movements by touching various spots in 
the intestines with a sodium or a potassium salt, and thus proved 
beyond all doubt the presence of nerve centres within the wall of 
the intestines. 

The relations between the cerebro-spinal nervous system and 
intestinal movements are very complicated. The pneumogastric 
undoubtedly plays a certain part here, for irritation of that nerve 
causes or increases a movement throughout the entire small, and 
the upper portion of the large, intestine. The entire large intestine, 
according to the latest researches of Pal * receives motor fibres from 
the pneumogastric. We know from Pflugers celebrated experi- 
ments that the splanchnic nerve inhibits intestinal peristalsis. This 
inhibition may be direct, or it may be brought about indirectly by 
the anaemia which results from irritations of the splanchnic. Ac- 
cording to the most recent experiments of S. Mayer and von Basch, 
the splanchnic nerve exerts an inhibitory influence only as long as 
the blood in the capillaries is not venous ; when the blood becomes 
venous, then stimulation of this nerve causes increased peristalsis. 
Investigations of ]N~asse show that the splanchnic also contains direct 
motor fibres, but Pal 39 concludes from his experiments that the 
action obtained is a reflex one. In like manner, stimulation of the 
cortex of the brain and of the optic thalamus may inhibit or accel- 
erate intestinal movements : the acceleratory stimulus passes through 
the pneumogastric, the inhibitory through the spinal cord (Bechte- 
rew and Mislowski m ). 

J. Pal M has furthermore shown that the splanchnic centre is not 
the only inhibitory one of the small intestines, but that there are 
others lower down in the spinal cord. 

Contrary to the small intestines and the upper part of the large, 
the lower part of the large intestine and the rectum receive acceler- 
atory as well as inhibitory fibres from the sympathetic. 

In connection with innervation of the rectum, Fellner 41 has called attention 
to a remarkable antagonism existing between the nervi erigentes and the nervi 
hypogastrici of the dog. Whereas the former nerves contain motor fibres for 
the longitudinal and inhibitory for the circular muscles, the reverse is true of 
the hypogastric. L. Exner 42 disputes the evidences lent by Fellner's experi- 
ments, but they have recently been confirmed by Pal 43 . 

Normal peristalsis may be increased or diminished through ex- 
ternal as well as internal agencies. The external agencies include 
cold, massage, and the faradic current ; the internal, mechanical, 
chemical and thermal, vaso-motor and central stimulation. Those 



36 DISEASES OF THE INTESTINES 

mechanical agencies which cause an increase in normal peristaltic 
movement are foreign bodies, stenoses, parasites, and particularly 
indigestible foods ; the chemical agencies include laxatives and 
tainted food stuffs, with their accompanying products of decomposi- 
tion. The thermic excitants of peristalsis are cold, especially in the 
form of cold drinks, ice, or of cold injections. Circulatory disturb- 
ances resulting from congestion of the portal system may cause an 
increase or a slowing of peristalsis. Finally, we may have increased 
peristalsis resulting from certain conditions of the central nervous 
system — e. g., crises enteriques of tabes, tormina ventriculi nervosa 
(Kussmaul), in neurasthenics, hysterics, etc. 

Conversely, similar conditions may cause the peristalsis to dimin- 
ish, or to cease entirely. Mechanical causes are very frequently 
found in women; retroflexion of the uterus is one of the best 
known, although not the only example. 

As examples of thermal sedatives, we have warm, moist applica- 
tions (cataplasma) and warm enemata. Where we have increased 
intestinal movements, the diet employed may, from its nature, act 
as a chemical sedative — e. g., gruels in diarrhoeas. The narcotic 
drugs (opium and its derivatives, belladonna, etc.) should be classed 
with those chemical agents which diminish intestinal peristalsis. 
The latter may also be indirectly influenced by remedies which 
tend to diminish intestinal secretion (the so-called astringents). 

In the course of many diseases of the intestinal mucous mem- 
brane there is a gradual decrease in normal intestinal excitability. 
In intestinal stenosis we may have a temporary or a permanent 
paralysis, resulting from paretic effects of fluid or gaseous prod- 
ucts. Disturbances of intestinal circulation (haemorrhoids, con- 
gestion accompanying uncompensated valvular affections, etc.) 
frequently cause a decided slowing of peristalsis. Furthermore, 
central nervous impulses may not only accelerate, but may weaken 
or even inhibit intestinal movements — e. g., meningitis, cerebral tu- 
mours, etc. In functional neuroses (neurasthenia, hypochondriasis, 
and hysteria) there may be a marked diminution in the peristaltic 
movements. Lastly, feeble peristalsis has been observed as a con- 
genital inherited condition. 

INTESTINAL ABSORPTION 

The intestinal canal is the principal seat of food absorption. 
As has been proved by the most recent researches of von Mering, 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 37 

Moritz, Hirsch, and Brandt, the absorption of substances (even 
in solution) from the stomach is very limited. It has been dem- 
onstrated that besides water, the intestines also absorb peptones 
(or albumoses) as well as the various saccharins, salt solutions, 
and fats, and give up these substances to the lymph and blood 
channels. 

Formerly absorption was regarded as a purely physical process — 
for the most part one of simple diffusion. But since colloids (albu- 
mins and gelatins) have very poor osmotic properties, this explana- 
tion would apply to crystalloid substances only (salt and sugar). 
Furthermore, this theory does not account for the entrance of the 
fats into the chyle. The view which is now accepted is that absorp- 
tion of food particles results mainly from a specific function of the 
living protoplasm. This theory has sprung up within recent years, 
and has been evolved from the studies of Hoppe-Seyler, Heiden- 
hain, I. Munk, and others. 

We shall now briefly describe the manner in which absorption 
takes place in the intestines. First, as regards the absorption of 
peptones. It is well known that peptones do not enter the blood 
current as such, but in the form of albuminoids. This change is 
essential, for it has been proved that peptones injected into the 
blood are quickly excreted by the urine (Plosz and Gyergyay 44 , 
Hofmeister 45 ). Consequently peptones must be converted into 
albuminoid bodies before they enter the blood. Opinion is divided 
among physiologists as to where this conversion takes place. Thus 
Hofmeister 46 ascribes the greater importance in assimilation and 
absorption of the proteids to the leucocytes found so plentifully 
upon the surface of the intestine during digestion ; whereas Heiden- 
hain 29 credits the leucocytes with but a very minor part in the 
reconversion of albuminoids from peptones, and ascribes this rather 
to the epithelial layer of the villi. 

It is important to inquire into the utilization of albuminoids 
where pancreatic juice is entirely absent. After complete extirpa- 
tion of the pancreas in dogs, Abelmann 47 and Minkowski found 
an average utilization of 44 per cent of albumin ingested, while, 
after partial extirpation, 54 per cent was utilized. Similar experi- 
ments of Sandmeyer 48 showed a utilization of from 62 t per cent 
to 70 per cent, which was markedly increased by the administration 
of raw beef pancreas. In the latter instance, figures coinciding 
fully with those from normal animals were obtained. 

As regards absorption of the carbohydrates, that of glucose 
4 



38 DISEASES OF THE INTESTINES 

levulose and galactose is direct, while maltose and cane sugar are 
first converted into glucose within the intestines, and as such are then 
absorbed. Experiments of Ludwig and von Mering 49 upon lower 
animals, and of I. Munk and Kosenstein ^ upon man, tend to show 
that carbohydrates are not absorbed through the chyle vessels, but 
pass directly into the blood. Should there be an excess of blood 
in the intestine, some of the sugar will pass directly into the chyle 
vessels and into the thoracic duct (Ginsberg 51 ). It appears from 
the investigations of Hoppe- Sevier 2 , von Mering 49 , and Otto 52 , that 
cane sugar as well as dextrinlike substances may be found in the 
blood, though only in small quantities. 

There is also a limit to the amount of sugar which can be con- 
veyed to the blood-vessels of the liver ; when this limit is exceeded, 
the excess in all probability passes directly into the lymphatic sys- 
tem and is not brought to the liver at all. A portion of it readily 
appears in the urine (alimentary glycosuria). The so-called " limit 
of assimilation " varies with the individual person as well as with 
the variety of sugar.* Sugar is stored up in the liver and to a less 
extent in the muscles and glands, in the form of glycogen, a non- 
oxidizable substance. The pancreas is the main though not the 
only factor in the digestion and absorption of sugars. Although 
Minkowski and Abelmann 47 found that only 57 to 61 per cent of 
starches were absorbed after total extirpation of the pancreas in 
dogs, the experiments of Fr. Muller 53 on man have nevertheless 
shown that, even with total occlusion of the pancreatic duct, starches 
are absorbed with hardly any loss whatever. 

Fats are absorbed in the intestines after previous emulsification 
by the pancreatic secretion and the bile. Owing to the great abun- 
dance of alkalies present, the fatty acids are converted into soaps. 
Fats are very probably absorbed through the lymphatics. This has 
been proved by the investigations of Munk and Rosenstein 50 in 
their case of lymphatic fistula. In their experiments they found 60 
per cent of the fats originally given in the chyle, and only 4 to 5 
per cent of that amount was saponified. Furthermore, upon feed- 
ing with erucic acid, a fat entirely foreign to the body, they again 
obtained 37 per cent, and this in the form of neutral fat. It follows 
from this that the fatty acids do not enter the lacteals in their orig- 
inal form, but as neutral fats. I. Munk assumes also that fatty soaps 
are for the greatest part converted into neutral fats before entering 
the lymphatics. 

* Compare von Noorden, Pathologie des Stoff wechsels, Berlin, 1893. 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 39 

To sum up, absorption of the fatty portion of the food takes 
place as follows : 1. Finely emulsified fat, as such, is either taken up 
by the migratory lymph cells lying upon the free surface of the 
intestinal wall (Zawarykin w and Wiedersheim 55 ), or else it passes 
directly into the villi, entering between the spaces at the base of the 
cylindrical epithelia (HeideDhain). 2. Fatty acids are converted 
into neutral fats, and are likewise taken up by the lymphatics. 
3. Fatty soaps are reconverted into neutral fats and taken up by 
the lymphatics. Since fatty acids, as such, are not found again in 
the chyle, we must assume with I. Munk 56 and von Walther 5? that 
they are converted within the intestinal wall into neutral fats by the 
addition of glycerin, or even upon the intestinal surface itself (von 
Walther). 

As regards the soaps, it would appear as though they could 
combine with glycerin to form neutral fats within the parenchyma 
of the villi. We must, however, admit the impossibility of explain- 
ing the source of the glycerin necessary for this change. Possibly it 
may be a portion of that made free in the splitting up of fat by the 
pancreatic secretion ; at all events, the investigations of Perewozisn- 
koff 58 , and the later ones of Will 59 and C. A. Ewald 60 , have shown 
that the living intestine is capable of forming neutral fats when 
the component parts, fatty acids and glycerin, or fatty soaps and 
glycerin, are introduced into it. Neumeister 28 quite correctly 
points out that the epithelial cells play an important part in this 
conversion. 

Variety and constituency of the fats are of great importance in 
determining their digestibility. I. Munk 61 and Arnschink 62 have 
shown that fats with a high melting point (mutton tallow, stearin, 
etc.) are not so completely absorbed as the more easily melted fats 
(lard, goose fat, olive oil, butter, etc.). According to Munk and 
Posenstein ^ a firm fat like mutton tallow is more slowly absorbed 
than a fluid like lipanin. Besides this, a free fat is more readily 
absorbed than one which, like lard, is inclosed in an envelope 
(Pubner 63 ). I find interesting the fact mentioned by Fleischer w , 
that Hippocrates had already referred the difficulty in the digesti- 
bility of eels to the stearin contained in them. 

How does occlusion of the pancreatic duct or extirpation of the 
pancreas affect fat digestion ? The absence of pancreatic juice is 
certainly of great importance in this connection. According to 
Minkowski and Abelmann 47 , all fats (neutral as well as mixtures 
of fatty soaps and fatty acids) fed to dogs under these conditions 



40 DISEASES OF THE INTESTINES 

appear in the fseces. Milk forms the only exception; over half 
of its fat is absorbed. An increase in the absorption of fat was 
observed when pancreas of beef or pig was added to the food. 
Other experiments upon the absorption of fat, especially in man, con- 
trast with the results just cited. Thus Sandmeyer 48 found great 
variations in the absorption of unemulsified fats in his dogs (0-78 
per cent). Where emulsified fats in the form of milk were given, 
42 per cent was absorbed. Teichmann 65 found no alteration in 
fat absorption in rabbits in whom the pancreatic duct had been 
tied. Fr. Muller 53 found rather abundant fat absorption in a case 
of pancreatic fistula consequent upon the extirpation of a cyst. 

Though the results just enumerated are so very contradictory, it 
is not incorrect to assume that disturbances in the assimilation of 
fat arise wherever there is a long-continued exclusion of pancreatic 
juices, and (as is usually the case in man) also of the bile. From 
this it by no means follows that these secretions are indispensable 
to the support of life, for there are apparently vicarious forces which 
to a certain extent can offset the disturbances occasioned by the 
absence of these digestive secretions. 

Absorption from the large intestine is relatively unimportant. 
However, when the activity of the upper portions of the absorptive 
system is in abeyance, the large intestine may for a time act 
vicariously. This we learn from the employment of rectal nutri- 
tion. Water, especially, is very readily absorbed from the large 
intestine. As proved by Eichhorst 66 , Yoit and Bauer 67 , Leube 68 , 
Ewald 69 , Huber 70 , and Kohlenberger 71 , albuminoids and albumoses 
are also absorbed from the rectum and the large intestine. My 
own experience with milk has taught me that it is almost entirely 
absorbed from the lower segment of the large intestine. Starch 
which has not been converted into sugar is slowly acted upon by the 
bacterial ferments, and ultimately decomposed into lactic acid, buty- 
ric acid, etc. 

Fats, especially emulsified fats, are slowly absorbed from the large 
intestine (Kobert 72 , Munk and Eosenstein 50 , P. Deucher 73 ). The 
amount taken up is, however, comparatively slight, only 10 per 
cent of that present in a rectal injection being absorbed (Deucher). 
The absorption of oils may be increased by the addition of normal 
salt solution. 

The immediate result of a liberal absorption of food constituents 
from the intestines is a gradual increase in the consistency of the 
residue, which slowly assumes the form of normal fasces. At the 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 41 

same time the acid reaction of the masses becomes gradually neutral 
or feebly alkaline. 

THE EXCRETORY FUNCTION OF THE INTESTINAL 

CANAL 

Besides absorption and secretion, the intestinal canal, like the 
stomach, has also the function of excretion. It may thus rid itself 
of superfluous substances as well as of waste materials from the 
blood, all of which it excretes with the fgeces. This function of the 
intestines, which has been closely studied within the last few years, 
is also of clinical interest, and therefore deserves brief mention. 

We know from Hermann's experiments 74 with animals, but 
even more so from Fr. Muller's experiments 75 , in connection with 
Senator, Lehmann, I. Munk, and Salkowski, upon the two profes- 
sional fasters Cetti and Breithaupt, that during fasting the faeces 
contain a number of organic and inorganic substances, a portion of 
which, at least, must be regarded as excreted matter. Kobert ra de- 
serves credit for having made similar studies upon the isolated large 
intestine of men, and for having thus determined the share taken in 
excretion by that portion of the intestinal canal. He found that in 
twenty-four hours an inactive large intestine excreted an average of 
0.9684 grammes dry substance, the percentage of whose ingredients 
varied from 3.35 per cent inorganic and 96.65 per cent organic 
ingredients, to 57.52 per cent inorganic and 42.48 per cent organic 
substances. The inorganic ingredients were sodium, calcium, mag- 
nesium, iron, and phosphoric, sulphuric, and hydrochloric acids ; 
the organic, mucin, albumin, keratin, fatty acids, soaps, and neu- 
tral fats. A large proportion (12.793 per cent) of the inorganic 
substances consisted of calcium and of phosphoric acid (44.52 per 
cent). This substantiates the results of Fr. Muller's experiments 
on dogs, as well as those of von Noorden and Belgardt 76 on man, in 
which they found large amounts of calcium and phosphates in the 
excretions, particularly in those from the large intestine. From 
investigations in a case of fistula of the ileum, Honigman 77 recently 
arrived at the same conclusions. Particular interest lends itself 
to the discovery made by Kobert, that the large intestine can also 
excrete fat. He found that the total amount varies from 9.32 per 
cent to 6.48 per cent of the dried substance ; 90 per cent of this 
total amount being fatty acids, 9 per cent neutral fats, and the 
remainder fatty soaps. From this it may be seen that intestinal 



4-2 DISEASES OF THE INTESTINES 

excretion constitutes an important auxiliary to the functions of 
the kidney. The occurrence of profuse diarrhoeas in extensive 
parenchymatous changes of the kidneys is in all probability an 
attempt on the part of the organism to vicariously rid itself of waste 
material through the intestinal canal. From investigations thus far 
made, we would regard the large intestine as most actively partici- 
pating in this vicarious action. 

THE NATURE AND COMPOSITION OF THE FAECES 

The faeces are made up partly of food which is either indiges- 
tible or has not been acted upon by the digestive juices, partly of 
the secondary products of digestion, and lastly from the remnants 
of the secretions and excretions of the digestive tract itself. In 
this latter connection it should be remarked that the empty intes- 
tine may produce faeces through its secretions and its exfoliated 
epithelium (so-called Ring'kotli of L. Hermann 74 ). 

The composition of the faeces naturally varies very much accord- 
ing to the nature and range of the diet, Under a vegetable diet 
the faecal masses are much bulkier than under an animal one. As 
an example of this, Voit 78 states that the excrements of a man under 
a mixed diet amounted to 120-150 grams, with 30-37 grams solids 
in twenty-four hours ; while those from a vegetarian equalled 333 
grams, with 75 grams solids. The colour of the faeces is to a cer- 
tain degree also dependent upon the diet. Under mixed diet it 
is dark brown ; under milk diet, brownish yellow ; and brownish 
black, or even deep black, under meat diet. 

Among the food ingredients found in normal faeces are muscle 
fibres, connective tissue, casein particles, starch fragments, fat, vege- 
table remnants, horny substances, nuclein, etc. The intestinal mu- 
cous membrane and its secretions contribute mucin, cholic acid, 
dysalin, and cholesterin. The products of intestinal putrefaction 
found in the faeces include skatol, indol, volatile fatty acids (acetic 
acid is said to be constantly present in faeces), calcium, and magne- 
sium soaps. Of the inorganic salts in the faeces, the readily soluble 
alkaline chlorids occur but rarely, while the insoluble combinations 
— ammonium magnesium phosphates, calcium carbonate, neutral 
calcium phosphate, and magnesium phosphate — are, on the con- 
trary, very frequently met with, being for the most part derived 
from the food. 

Bacteria and other micro-organisms occur in large numbers in 



PHYSIOLOGICAL AXD PHYSIOLOGICO-CHEMICAL REMARKS 43 

the faeces : according to Woodward T9 . they constitute a very con- 
siderable portion of the faeces. The only bile pigment found under 
normal conditions is urobilin (stercobilin) ; the occurrence of biliru- 
bin or bihverdin is pathologic. 

Careful quantitative analyses of the faeces have often been made, 
but, as might have been supposed, they have given widely varying 
results. We would therefore desist from mentioning them. 



INTESTINAL DIGESTION IN ITS ENTIRETY 

In attempting a description of intestinal digestion in toto, we 
encounter serious obstacles: for our knowledge of this subject in- 
cludes a number of isolated processes which can not be grouped 
together without the aid of some hypotheses. 

What impulse excites intestinal secretion ( The opening of the 
pylorus acting renexly very likely causes an increased secretion of 
bile and of pancreatic juice. Concerning the pancreatic secretion. 
we know from the experiments of Heidenhain 80 and Bernstein 81 
that it begins to flow simultaneously with the ingestion of food, and 
reaches its maximum in from two to three hours. Thereupon the 
amount declines till the fifth to the seventh hour, increasing anew 
from the ninth to the eleventh, and then gradually declining again 
from the seventeenth to the twenty-fourth hour, when it finally 
ceases. 

As regards the bile, we know that it decreases during fasting, 
and is secreted again after ingestion of food. According to Heiden- 
hain, two maxima in rapidity of its secretion are observed in dogs : 
the first from three to five hours after food ingestion, and the 
second from thirteen to fifteen hours. Investigations of Eossbach 82 
yielded similar results. In all probability, therefore, the chyme 
meets with an active digestive juice when it enters the intestinal 
canal. 

The action of the intestinal juices upon the products of stomach 
digestion is still a matter of controversy. Physiologists, particu- 
larly Kiihne, ascribe to bile the property of precipitating and 
destroying not only the albumin and gelatin, but also the pepsin 
of the stomach contents. From this it would seem as though 
the precipitation of the pepsin within the small intestines was of 
extreme importance for digestion. However, my own investiga- 
tions 20 made with the pure mixed secretions from the intestines 
of man (i. e., mixtures of bile, pancreatic juice, and probably also 



44 DISEASES OF THE INTESTINES 

the secretion from the glands of Lieberkiihn) have shown that these 
views are incorrect. What does occur is rather as follows : The 
first faintly acid portions of the chyme occasion alterations in the 
intestinal juices only in so far as they acidify these to a slight 
degree, whereby, as we have already seen (see page 27), no de- 
struction of the active intestinal ferments occurs. It is true that 
with the entrance of strongly acid chyme into the small intestine 
a precipitation of the albuminoids — but not of the gastric ferments 
— follows. However, a mixture of duodenal juices and stomach 
contents with the latter in such proportion that free hydrochloric 
acid is present exhibits solely and distinctly the characteristics of 
a pepsin-hydrochloric-acid solution. Rennet ferment also is pre- 
served intact in such a mixture. If we alkalinize such a mixture 
with dilute soda solution, we may — for a short time at least — be 
able to observe tryptic action. Later this action can not be brought 
out because the trypsin is destroyed by the continued action of 
the gastric acid. It is therefore very probable that in the first 
stages of intestinal digestion there is simply a continuation of the 
gastric digestion. Gradually, however, as the intestinal juices in- 
crease and the amount of strongly acid stomach chyme poured into 
the duodenum diminishes, pepsin digestion gives way to that of 
trypsin. My observations have recently, in great part, been con- 
firmed by Fleischer 64 and Meltzer. 

In spite of the differences of opinion between physiologist and 
clinician, the above observations show that the reaction of the con- 
tents of the small intestines varies according to the stage of diges- 
tion. Even in the lowermost portion of the small intestines— as 
Nencki, Macfadyen and Sieber 83 found in a fistula in the lowest 
portion of the ileum — the reaction of the contents was acid, the 
acidity averaging one pro mitte (basis of acetic acid). 

As soon as the intestinal ferments can act with full force the 
digestion of food takes place, the individual ferments acting as 
already described. Proteids which have not yet been converted 
into albumoses are peptonized, with the additional formation of 
leucin, tyrosin, and of aspartic acid ; unconverted carbohydrates are 
at first altered into maltose and (a little) glucose, and finally com- 
pletely into glucose ; fats are split up into fatty acids and glycerin, 
and are in part emulsified — i. e., brought into an absorbable con- 
dition. 

In addition to these fermentative changes there are also bacterio- 
logical changes which to a certain extent affect the proteids and 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 45 

gelatinous substances, but to a far greater degree the carbohydrates. 
Their existence has been proved by the above-mentioned instructive 
investigations of Xencki, Macf adyen and Sieber ffi upon their case 
of fistula of the ileum. The chyme was of a yellowish or yellowish- 
brown colour and had an acid reaction. As a rule, excepting for a 
somewhat burnt smell reminding one of the volatile fatty acids, or 
still more rarely excepting for an odour of decomposition very like 
indol, this yellowish mass was entirely odourless. Besides acetic 
acid, fermentation as well as musclelactic acid, volatile, fatty, suc- 
cinic, and bile acids were also present. In large quantities of this 
chyme it was impossible either through sense of smell or through 
chemical examination to detect the merest traces of the character- 
istic decomposition products, such as indol, skatol, phenol, methyl 
mercaptan, or of their combinations, phenylpropionic acid, paraoxy- 
phenyl-propionic acid, and skatolacetic acid. 

"Without doubt the real seat of intestinal putrefaction is in the 
large intestine. The role in food digestion assumed by the large 
intestine is markedly less than that of the small. The experiments 
of Xencki, Macfadyen and Sieber showed that 85 per cent of the 
albumin ingested is digested by and absorbed from the stomach and 
small intestines, so that but about 15 per cent remains for the large 
intestines. Undoubtedly digestion does take place in the large 
intestine, but it is more bacterial than fermentative. Another chief 
difference from small intestinal digestion is the formation not only 
of useful products, but also of others harmful to the economy. It 
is questionable, however, if all bacterial by-products are utterly use- 
less in intestinal digestion — if, for example, certain products are 
not capable of favourably exciting peristaltic motion. 

The best-known decomposition products are those of albumin. 
They have been studied by many investigators, above all by Xencki, 
Baumann, Brieger and H. and E. Salkowski. The most important 
are indol, skatol, paracresol, phenyl-propionic acid, phenyl-acetic 
acid, hydroparakumaric acid, the volatile fatty acids, carbon-dioxide, 
hydrogen gas, methyl mercaptan, and sulphuretted hydrogen. 

Of these, the most important from a practical standpoint, are 
indol and skatol, because, as has been shown by the investigations 
of E. Baumann, they combine with the sulphates of the food (pre- 
viously oxidized to indoxyl and skatoxyl sulphates) to form ethe- 
real sulphates (indoxyl- sulphuric acid and skatol-sulphuric acid), 
and are excreted as such in the urine. They thus form a gauge 
(though not a constant one) for the putrefactive processes within the 



46 DISEASES OF THE INTESTINES 

intestines. Phenol passes into the urine as phenol -sulphuric acid ; 
the oxy-acids pass off unaltered with the urine. 

The carbohydrates, like the albuminoids, are also subject to 
bacterial decomposition. At the present time we recognise a large 
number of bacteria, which through fermentative action may on one 
hand convert starches into sugars, and on the other cause these 
very sugars to ferment. For example, the bacillus subtilis and the 
spirillum of cheese are both capable of converting starch into sugar ; 
but further long-continued action of the subtilis on this sugar 
results, according to van den Yelden, in fermentative production of 
lactic, butyric, and succinic acids. Some bacteria and yeasts can 
produce invertin, etc. ; others, again, such as the bacillus butyricus, 
convert lactic acid into butyric acid. As final products of carbo- 
hydrate fermentation we have a number of gases, the most important 
of which are carbon dioxid, hydrogen and marsh gas. 

Cellulose fermentation results mainly from the action of certain 
bacteria or vibrios. 

Fats are capable of fermentation, especially when in the form of 
fatty acids, but the special organisms as well as the different steps 
of the process are entirely unknown to us. 

[THE GASES OF THE INTESTINES 

The gases occurring within the intestinal tract are derived from 
three sources : 

1. They enter the bowel from the stomach. 

2. They pass from the blood into the intestines by diffusion. 

3. They are formed within the intestinal canal. 

Of these three sources the third is by far the most important 
and active. 

1. The gases that may enter the bowel from the stomach 
are : 

a. Air swallowed during or independently of the ingestion of 
food (oxygen and nitrogen). 

b. Gases contained in food, beverages, and medicated liquids. 
These consist mainly of carbonic acid, but small quantities of other 
gases may be introduced with the mineral waters (e. g., sulphuretted 
hydrogen in sulphur waters, etc.). 

c. Gases originating within the stomach. These are partly 
absorbed, partly escape from the body through eructations, but a 
certain portion passes into the intestines. In the early stages of 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 47 

normal gastric digestion, micro-organisms swallowed with the food 
cause some fermentation of the stomach contents with a result- 
ing formation of carbonic-acid gas and hydrogen. According to 
Miller, 84 this fermentation ceases as soon as a large amount of hydro- 
chloric acid has been produced. Schierbeck 85 has demonstrated 
that during digestion carbonic-acid gas is produced by the secreting 
cells of the gastric wall. Strauss 86 and Rosenheim 87 found ammo- 
nia present in very small amounts. 

Under pathological conditions (stagnation with or without the 
presence of hydrochloric acid, abscess of the wall, ulcerating carci- 
noma, etc.), in addition to the above-mentioned two gases, hydro- 
gen, sulphuretted hydrogen, ammonia, marsh gas, and other hydro- 
carbons may be produced. It is but natural to assume that with a 
patulous pylorus and fair or good gastric motility these abnormal 
gases may enter the intestines. 

2. Bunge 88 states that nitrogen, and Nothnagel 89 that carbonic- 
acid gas, enter the intestinal canal by diffusion from the blood. 

3. Throughout the entire intestinal canal gases are formed from 
digestive fermentation and bacterial decomposition of the food ; in 
the uppermost portion of the small intestine, from the action of acid 
gastric chyme and of the free acids of the fats upon the alkaline 
intestinal and pancreatic juices. The amount and kind of gas 
formed vary according to the diet and the segment of bowel in 
question. Gas formation is most rapid wherever active fermentative 
changes occur — i. e., in the upper segments of the small intestine. 
Accordingly, less gas is produced in the lower portion of the small 
intestine and very little in the large bowel. In the large intestine 
gas formation has almost or entirely ceased, and putrefactive decom- 
position and inspissation of the faeces take place. 

From the decomposition of the alkaline carbonates of the intes- 
tinal juices by the gastric chyme and fatty acids in the uppermost 
portion of the small intestine carbonic-acid gas is formed. After 
the acids have been neutralized, intestinal fermentation and decom- 
position begin. 

Of the solid food stuffs, the carbohydrates yield hydrogen, car- 
bonic-acid gas, and a small quantity of marsh gas, varying propor- 
tionately to the digestibility of the carbohydrates. Starchy foods 
result in the formation of but very little marsh gas, while, as we 
know from the experiments and investigations of Euge, 90 Tappei- 
ner, 91 and Planer, 92 those rich in cellulose yield more marsh gas than 
any other variety of food. Since cellulose is not altered by the gas- 



48 DISEASES OF THE INTESTINES 

tro-intestinal secretions of man, the formation of marsh gas is no 
doubt due to bacterial action. 

The gases that result from the digestion and decomposition of 
proteid material are formed more slowly than those from the car- 
bohydrates. These are hydrogen, carbonic acid, marsh gas, ammo- 
nia, sulphuretted hydrogen, and, according to Lehmann, Hagemann, 
and Zuntz, 93 nitrogen under certain specific conditions. 

As already mentioned, the fats, by the action of their fatty 
acids upon the alkaline intestinal juices, produce carbonic-acid gas. 

Considering the large quantity of gases normally present in the 
intestine * and the comparatively small amount passed as flatus, 
their absorption must be a very active one. Regnault and Rei- 
sert, 94 Tacke, 95 Zuntz, 93 and others, have demonstrated the pres- 
ence of marsh gas and other intestinal gases in the expired air. 

Under pathological conditions the quantity and composition of 
gases in a given segment will vary from the normal. It will depend 
upon the nature of the contents (amount of fermentative material 
and of fermenting agents — i. e., bacteria, moulds and yeasts), the 
motility of the bowels, and the condition of the circulation. 

In sluggishness or total arrest of the contents (e. g., atony, 
paralysis, obstruction, occlusion, etc.) there will at first be the prod- 
ucts of fermentation, later those of putrefactive decomposition. 
By his experiments Kader 96 showed that excessive formation of gas 
within the intestinal lumen was largely dependent upon the circula- 
tion in the mesentery. In those experiments in which the mesen- 
tery was ligatured, marked meteorism developed ; in those in which 
the gut alone was tied, very little gas developed. (See also page 363 
of this work.) 

Certain catarrhs, by offering conditions favourable to bacterial 
and fungoid growth, favour the increase of gases (Nothnagel 76 ). 
The same holds true also for ulcerative and sloughing conditions 
(carcinoma, dysentery, abscess, gangrene, etc.). 

On the other hand, in abnormally rapid peristalsis the contents 
pass so quickly through the intestine that only easily assimilated 
food stuffs are decomposed. The starches and sugars and carbon- 
ated beverages yield gaseous products within the body ; the more 
resistant carbohydrates, the fats, the proteids, connective tissues, 

* [A faint idea of the active formation that goes on may be gained by mixing a 
small amount of fresh faeces (about 5.0 grams) with a little water, placing the 
mixture in any kind of a fermentation tube, and allowing the tube to remain for a 
short time in an incubator at 37° C. — Tr.] 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 49 

and cellulose pass out very slightly or not at all altered. Hydrogen 
and carbonic-acid gas are mainly formed ; the fasces are often passed 
in a state of active starchy and saccharin fermentation — Tu.] 



LITERATURE 

1. Griitzner. Pfluger's Archiv, Bd. vii. S. 258. 

2. Hoppe-Seyler. Physiolog. Chemie, Berlin, 1877-'81, S. 274. 

3. Bunge. Lehrbuch der physiologischen u. pathologischen Chemie, Leipzig, 

1887, S. 183. 

4. Demant. Virchow's Archiv, Bd. Ixxv, S. 419. 

5. Brown u. Heron. Annal. Chem. und Pharm., 1880, Bd. cciv, S. 228. 

6. K. B. Lehmann. Arch, fur die gesamrnte Physiologic Bd. xxxiii, S. 180. 

7. Turby and Manning. Centralblatt f. die medicin. Wissenschaften, 1892, 

S. 945. 

8. Miura. Zeitschr. f. Biologie, Bd. xxxii, S. 266-287. 

9. Rohmann u. Lappe. Berichte d. deutsch. chem. Gesellschaft, Bd. xxviii. S, 

2,506 u. 2,507. 

10. Frick. Arch. f. wissensch. u. prakt. Thierheilkunde, Bd. ix, S. 148. 

11. Ellenberger u. Hofmeister. Ibid., Bd. x, S. 427. 

12. Wenz. Zeitschr. f. Biologie, N. F., Bd. iv, 1886. 

13. C. Schmidt. Annal d. Chemie, Bd. xcii, 1854, S. 34. 

14. Zawadsky. Centralbl. f. Physiologic, 1891, Bd. v. 

15. Herter. Zeitschr. f. physiolog. Chemie, Bd. iv, 1880, S. 160. 

16. Podolinski. Pfluger's Archiv, Bd. x, 1875, S. 557 u. Bd. xii, 1876, S. 422. 

17. S. G. Hedin. Du Bois-Reymond's Archiv, 1891, S. 273-278. 

18. R. Neumeister. Zeitschr. f. Biologie, K F., Bd. viii, 1890 ; and Winter- 

nitz, Zeitschr. f. physiolog. Chemie, Bd. xvi, 1892, S. 462. 

19. Maly. Jahresbericht, Bd. ix, S. 224. 

20. Boas. Zeitschr. f. klin. Medicin, Bd. xvii, Heft 1 11. 2, 1890. 

21. Musculus u. Gruber. Zeitschr. f. physiolog. Chemie, Bd. ii, 1878, S. 177. 

22. von Mering. Zeitschr. f. physiolog. Chemie, Bd. v, 1881, S. 185. 

23. Nencki. Arch. f. experiment. Pathologie u. Pharmakologie, Bd. xx, S. 

367. 

24. Boas. Deutsch. med. Wochenschr., 1891, No. 28. 

25. Baas. Zeitschr. f. physiol. Chemie, Bd. xiv, S. 416. 

26. Voit. Ueber die Bedeutung der Galle f. die Aufnahme der Nahrungs- 

mittel im Darmcanal. Festschrift, Mtinchen, 1882. 

27. Rohmann. Pflnger's Archiv, 1883, Bd. xxix, S. 509. 

28. Neumeister. Lehrbuch der physiolog. Chemie, 1893, Theil 1. 

29. Heidenhain. Pfltiger's Archiv, 1888, Bd. xliii, S. 91. 

30. Braam-Houkgeest. Pfltiger's Archiv, Bd. vii, 1872, S. 266. 

31. Nothnagel. Beitrage zur Physiologie u. Pathologie des Darms, Berlin, 

1884. 

32. Grutzner. Deutsch. med. Wochenschr., 1894, No. 48. 

33. Christomanos. Wiener klin. Wochenschr., 1895, Nos. 12 and 13. 

34. Dauber. Deutsch. med. Wochenschr., 1895, No. 34. 



50 DISEASES OF THE INTESTINES 

35. Wendt. Munch, med. Wochenschr., 1896, No. 19. 

36. Swiezynski. Deutsch. med. Wochenschr., 1895, No. 32. 

37. Riegel. Die Erkrankungen des Magens, Wien, 1896, S. 246. 

38. J. Pal. Wiener klin. Wochenschr., 1895, Nos. 29 and 30. 

39. J. Pal. Ibid., 1897, No. 2. 

40. Bechterew u. Mislawski. Arch. f. Anat. u. Physiol., 1889, Supplement- 

band. 

41. Fellner. Oesterr. med. Jahrbucher, 1883, S. 571 ; and Pfluger's Archiv, 

Bd. lvi, 1894. 

42. L. Exner. Pfluger's Archiv, Bd. xxxix, 1884, S. 310. 

43. J. Pal. Wiener klin. Wochenschr., 1895, Nos. 39 and 40. 

44. Plosz. u. Gyergyay. Pfluger's Archiv, Bd. vi. 

45. Hofmeister. Zeitschr. f. physiol. Chemie, Bd. v. 

46. Ibid. Archiv fur experiment. Pathol, u. Pharmakol., Bd. xix, xx und 

xxii. 

47. Abelmann. Ueber die Ausniitzung der Nahrungsstoffe nach Pancreasex- 

tirpation. Inaug. -Dissert., Dorpat, 1890. 

48. Sandmeyer. Zeitschr. f. Biologie, 1895, Bd. xxxi, S. 12. 

49. von Mering. Du Bois-Reymond's Archiv f. Physiologie, 1877, S. 379. 

50. I. Munk u. Rosenstein. Virchow's Archiv, 1891, Bd. cxxiii, S. 230. 

51. Ginsberg. Pfluger's Archiv, Bd. xliv, S. 306. 

52. Cited from Maly's Jahresb. f. Thierchemie, Bd. xvii, S. 134. 

53. Fr. Muller. Zeitschr. f. klin. Medicin, 1887, Bd. xii. 

54. Zawarykin. Pfluger's Archiv, 1883, Bd. xxxi ; 1885, Bd. xxxv. 

55. Wiedersheim. Freiburger Festschrift zum 56. Naturforscherversammlung, 

1887. 

56. I. Munk. Virchow's Archiv, Bd. lxxx. 

57. von Walther. Du Bois-Reymond's Archiv, 1890, S. 329. 

58. Perewozisnkoff. Centralbl. f. d. med. Wissenschaften, 1876, No. 47. 

59. Will. Pfluger's Archiv, Bd. xx, 1879, S. 255. 

60. C. A. Ewald. Du Bois-Reymond's Archiv, 1883, Supplementband, S. 302. 

61. I. Munk. Virchow's Archiv, Bd. lxxx, S. 10 ; Bd. xcv, S. 407. 

62. Arnschink. Zeitschr. far Biologie, Bd. xxvi, S. 434. 

63. Rubner. Ibid., Bd. xv, S. 115 et seq. 

64. Fleischer. Lehrbuch d. inneren Medicin, Bd. ii, Theil 2, S. 1,077. 

65. Teichmann. Mikroskop. Beitrage zur Lehre von d. Fettresorption, Inaug.- 

Dissert., Breslau, 1891. 

66. Eichhorst. Pfluger's Archiv, 1871, S. 570. 

67. Voit u. Bauer. Zeitschr. f. Biologie, Bd. v, 1869. 

68. Leube. Deutsch. Archiv f. klin. Medicin, 1872. Bd. x. 

69. Ewald. Zeitschr. f. klin. Medicin, 1887, Bd. xii. 

70. Huber. Deutsch. Archiv f. klin. Medicin, 1891, Bd. xlvii. 

71. Kohlenberger. Munch, med. Wochenschr., 1896, No. 47. 

72. Kobert. Deutsch. med. Wochenschr. 1894, No. 47. 

73. Deucher. Deutsch. Archiv f. klin. Medicin, 1897, Bd. lviii, S. 210. 

74. Hermann. Pfluger's Archiv, 1890, Bd. xlvi, S. 93. 

75. Fr. Muller. Virchow's Archiv, 1893, Bd. cxxxi, Supplementheft. 

76. von Noorden u. Belgardt. Berliner klin. Wochenschr., 1894, No. 10. 



PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 51 

77. G. Honigmann. Archiv f. Verdauugskrankheiten, 1896, Bd. ii, S. 296. 

78. Voit. Zeitschr. f. Biologie, 1889, Bd. xxv, S. 264. 

79. Woodward. Med. and Surg. Report of the War of the Rebellion, vol. i, 

Part 2, 1879. 

80. Heidenhain. Pfliiger's Archiv, Bd. x, S. 557. 

81. Bernstein. Arbeiten aus der physiolog. Anstalt zur Leipzig, 1869. 

82. Rossbach. Deutsch. Archiv f. klin. Medicin, Bd. xlvi, S. 296. 

83. Nencki, Macfadyen u. Sieber. Archiv f. experimentelle Pathologie u. 

Pharmakologie, Bd. xxviii, S. 311-350. 
[84. Miller. Deutsch. med. Wochenschrift, 1885, No. 49.] 
[85. Schierbeck. Scand. Arch, of Physiol., vols, ii and iv. Quoted from Ham- 

marsten's Lehrb. d. physiolog. Chemie., 1895, 3te AufL, S. 246.] 
[86. Strauss. Berl. klin. Wochenschr., 1893, No. 17.] 
[87. Rosenheim. Centralbl. f. klin. Medicin, 1892, No. 39.] 
[88. Bunge. Lehrbuch, etc., S. 268.] 
[89. Nothnagel. Darm u. Peritoneum, 1898, S. 64.] 

[90. Ruge. Sitzungsber. d. Wiener Akademie d. Wissenschaften, 1861, Bd. xliv.] 
[91. Tappeiner. Zeitschr. f. Biologie, 1893, Bd. xix, S. 223.] 
[92. Planer. Sitzungsber. d. Wiener Akad. d. Wissensch., 1860, Bd. lxii, S. 307.] 
[93. Hagemann, Lehmann u. Zuntz. Landwirthschaftliche Jahrbiicher, 1894, 

S. 125.] 
[94. Regnault u. Reisert. Quoted from Nothnagel, loc. cit., p. 64.] 
[95. Tacke. Ueber d. Bedeutung d. brennbaren Gase im menschlichen Orga- 

nismus. Inaug. -Dissert., Berlin, 1889.] 
[96. Kader. Deutsch. Archiv f. Chirurgie, 1891, Bd. xlii, S. 57, etc.] 



DISEASES OF THE ENTESTENES 



PART I 
GENERAL DIVISION 



CHAPTEE III 
THE HISTORY 

In diseases of the intestines the history is of almost greater 
importance than in gastric affections. In the latter the diseased area 
is very limited ; in the former it is far more extensive. Whereas 
in gastric disease we can determine the condition through physical 
and functional examinations alone, in intestinal diseases we are com- 
pelled to rely mainly, sometimes even entirely, upon the statements 
of our patients. Too much care, therefore, can not be expended in 
obtaining as complete a history as possible. 

Naturally here, as elsewhere, our first inquiry should not be con- 
cerned with the local disturbances, but with the patient's previous 
general health. Hereditary tendencies must be taken into account. 
Our view of a case may be radically influenced by the existence of 
special dyscrasias, as syphilis, tuberculosis, etc., or by learning of 
the habitual employment of poisons which we know from experience 
to be injurious to the gastro-intestinal tract (alcohol, tobacco, lead, 
mercury, tin, zinc, arsenic, antimony, etc.). Special interest is 
imparted to a case by a previous history of infectious diseases, par- 
ticularly such as have local manifestations in the intestines — e. g., 
typhoid, cholera, dysentery, intestinal tuberculosis, etc. Owing to its 
etiological relations to cancer, a traumatism received prior to the 
development of a disease merits special consideration. In the 
female, the sexual apparatus should receive due attention, since it is 
frequently a cause of intestinal troubles. We should inquire par- 
ticularly into the menstrual condition, childbirths, previous opera- 
tions, as well as regarding any special symptoms the patient may 
have noticed (leucorrhcea, menorrhagia, metrorrhagia, pains, pres- 
sure, etc). In men, too, there is frequently a direct connection 
between diseases of the sexual organs and those of the intestines, so 
that careful inquiry ought never to be omitted. I need but recall 
diseases of the prostate gland. It is only after having thus obtained 
a clear and complete oversight of any other local or general affec- 

55 



56 DISEASES OF THE INTESTINES 

tions, which at first seem to have no connection with the present 
symptoms, that we ought to inquire into the details of the affec- 
tion in question. 

Regarding those points referable to gastric digestion, the reader 
is referred to Part I (general section) of my work on Diseases of 
the Stomach. There the most important facts bearing upon intes- 
tinal disturbances are discussed. 

"Whenever there is a suspicion of intestinal disease a most 
thorough local examination is indispensable. We may begin with 
the symptoms complained of by the patient, or, preferably, we can 
pursue a definite plan of inquiry which shall include all the anam- 
nestic data that can be gained from the history of a case. 

The following scheme has been of great service to me for many 
years : 

1. Pain along the Course of the Intestines 

(a) Seat of the pain. 

(b) Origin of the pain ; acute or chronic ; paroxysmal. 

(c) Character of the pain ; burning, boriug, stabbing, tearing, 

colicky, lancinating. 

(d) Duration of the pain. 

(e) Relation of pain to digestion ; how influenced, if at all, by 

quantity and variety of food. 

(f) Does the attack of pain cease with the passage of wind or 

of stool ; or have these no influence upon the pain ? 

(g) How do rest and motion affect the pain ? 

(h) What is the effect of manual pressure upon the painful 
area ? 

As a rule, the statements of the patient regarding the seat of the 
pain are not conclusive for the physician ; for it requires very good 
powers of observation to properly describe to the physician the 
point of origin of the pain, its extent, etc. Should the pain become 
intense, the patients naturally think less of its exact situation than 
they do of its severity. Pain in one region of the intestines alone — 
that of the vermiform appendix or of the caecum — is so very char- 
acteristic that even the layman can localize it quite well. Its distinct 
localization indeed differentiates caecal from similar pains. If the 
patient tells us that the pain is continuous, that it increases upon 
motion and diminishes with rest, that the painful area is sensi- 
tive to pressure, that the attack began with fever, and perhaps 
that similar attacks have already occurred, the diagnosis of appen- 



THE HISTORY 57 

dicitis or typhlitis is almost certain. Similarly, at least in well- 
developed cases of round ulcer of the duodenum, we find a strictly 
circumscribed area of tenderness.* This pain is characterized by 
its situation in the prolongation of the right parasternal line some- 
what below the gall bladder. Usually the pain begins three or 
four hours after a meal, and rarely or never radiates toward the 
back; it is worse after the ingestion of solid food and less after 
a fluid diet ; rest diminishes and bodily movements increase it. If 
the patient be of the male sex, and his statements coincide with 
what has just been said, there is at least a well-grounded suspicion 
of duodenal ulcer, and we should keep this in view in making our 
examination. 

Typical cases with pronounced symptoms, such as are described 
in text-books, are very rare. These are the classical cases which 
every physician knows. In the great majority of cases a probable 
diagnosis of the real condition can only be arrived at after repeated 
questions as to the location, character, and intensity of the pain. If 
the patient be seen during his attack of pain, we may sometimes 
come to a rapid conclusion concerning the nature of the case from 
the general behaviour, the facial expression, the character of the 
patient's crying or groaning, etc. For example, the painfully 
anxious and depressed facial expression of peritonitis, with the 
increased respirations, the rapid small pulse contrasting with a high 
temperature, the instinctive dread of the slightest contact and of 
pressure even of the bedclothes, are so characteristic that an expe- 
rienced physician, simply from hearing such symptoms described, 
will at once recognise a serious condition, although he may not be 
certain as to the exact diagnosis. 

The pain accompanying acute or chronic intestinal stenosis or 
occlusions is not so well characterized. Treves 1 makes the general 
statement that the pain of complete obstruction is constant (although 
subject to exacerbations), while that of partial obstruction is inter- 
mittent, alternating with intervals of freedom from pain. My own 
views coincide fully with Treves' s, although, as he himself admits, 
exceptions to the rule occur. In other respects the pain which 
accompanies intestinal occlusion and stenosis offers nothing diag- 
nostic. From this, however, it should not be inferred that the 
pain of ileus is like that of volvulus of the sigmoid, or like that of 



* Round ulcers of the jejunum or the ileum are very rare, and, as a rule, can not 
be diagnosticated. 



58 DISEASES OF THE INTESTINES 

an invagination or even of an obstruction caused by a foreign body, 
but rather that it is difficult, or even impossible, to make use of these 
distinctions in the differential diagnosis. We shall return to this 
point in the special part of this work. Similar difficulties are 
encountered where there is a history of periodic attacks of pain. If 
a long interval has elapsed between the time of the last attack and 
of our examination, the statements of the patient will be uncertain, 
and for the most part guesswork. In such a case we must seek to 
establish a connection between the paroxysms of pain and the intes- 
tinal functions — viz., to learn if obstinate constipation ordinarily 
precedes the attack, if the abdomen is full and distended, and, finally, 
if the passage of gas from above or from below, or of a copious stool, 
causes the paroxysms to cease. These phenomena very probably 
point to flatulent colic, although they may also occur with chronic 
intestinal stenosis. Even in the absence of constipation, more or 
less severe colicky pains may also be caused by decomposed food 
which remains for some time within the intestinal canal. Even 
though we may not at first discover any etiological factor, obstinate 
constipation complicating intestinal colic should lead us to think of 
lead colic (colica saturnica). Our inability to establish any connec- 
tion between the paroxysms of pain and the gastro-intestinal func- 
tions by no means justifies our declaring the pains purely " nervous," 
and thereupon, as careless examiners or novices so frequently do, 
construing a picture of hysteria or of neurasthenia from answers 
which the patient makes to leading questions. We should first 
examine those other organs which frequently cause paroxysms of 
pain — above all, the liver, kidney, pancreas (?), and the bladder — 
since stone colics occur in these organs. In women, the uterus, 
adnexa, etc., must be examined. 

One who knows from experience that severe gastralgias and 
enteralgias may be caused from very small supraumbilical or crural 
hernias, and by apparently insignificant preperitoneal lipomata, will 
be very careful before making the diagnosis of " nervous intestinal 
pain." At all events, I wish to state here that " enteralgias," as 
purely functional neuroses, occur much more rarely than, for exam- 
ple, gastralgias. (For further details, see chapter on Intestinal 
Neuroses in the special part of this work.) It is scarcely necessary 
to mention that whenever we have a well-grounded suspicion of 
enteralgia the central nervous system should be most carefully 
examined (crises enteriques of tabes, of myelitis, and of progressive 
paralysis). 



THE HISTORY 59 

The individual causes which may occasionally give rise to intestinal pain 
are too numerous to mention. I simply wish to state that we should remember 
that this pain may be due to swallowed foreign bodies (needles, fish bones), to 
entozoa,* or more so even to poisonous metabolic products such as occur, for 
example, after death, or disease of tapeworms and other intestinal parasites. 
Lastly, we must consider the possibility of nicotin poisoning. 

It is of great diagnostic importance to give a careful description 
of rectal pain. The nature of these pains varies considerably with 
their cause. When limited to the rectum, the pains may be press- 
ing, boring, burning, or even colicky in character. They may be 
continuous, or may occur for a short time only, before, after, or 
during a faecal evacuation. These rectal pains may be caused by a 
simple coprostasis in the ampulla recti (the latter sometimes acquir- 
ing enormous dimensions). They may be due to haemorrhoids, to 
fissures or fistulae, to rectal ulcers (tuberculosis, faecal ulcers, degen- 
erated syphiloma), or, finally, to stenoses of the rectum from tumours 
or cicatricial contractions. It is best not to spend too much time 
upon the consideration of these different possibilities. In most cases 
we can at once discover the condition present by digital examina- 
tion, aided perhaps by further examination with the speculum. 

Anal pains may likewise be due to strangulated haemorrhoids, to 
fissures of the mucous membrane, to fistulae, or to periproctitis. 
Here, too, direct inspection is the surest means of ascertaining the 
cause of the symptoms. 

2. Meteorism, Tympanites 

(a) Acute, chronic, or paroxysmal. 

(b) Local or general. 

Meteorism is a symptom which, when developed to a marked 
degree, may be complained of by the patient. To be sure, a so- 
called " meteorism " not infrequently turns out to be an ascites. 
Meteorism is of diagnostic significance only when taken in connec- 
tion with the rest of the symptoms. It may be caused solely by the 
ingestion of food abnormally rich in gases, or which forms gases 
(carbonated liquids, sauerkraut, the so-called " bloating substances "). 
The statement that meteorism has suddenly occurred in connection 

* Recently I have observed a case referred to me by Dr. Perel, of Odessa, in 
which very severe and constant intestinal pains were caused by the taenia nana. 
As is well known, the pains caused by the taenia solium or mediocanellata are mild, 
or altogether wanting. 



60 DISEASES OF THE INTESTINES 

with constipation is important, for this association may speak for a 
simple coprostasis ; we may, howeyer, haye to deal with retention 
of gases in a commencing obstruction, an incarcerated hernia, an 
inyagination — in short, with any condition which can obstruct the 
downward passage of gases, or eyen with an acute diffused or cir- 
cumscribed peritonitis. It may eyen be one of those singular 
gaseous distentions occurring in hysterical persons, which may 
prove a source of great anxiety and of error to the novice. 

Before beginning the objective examination, close questioning 
may enable us to form a correct idea of the true condition present. 

Chronic meteorism, more or less circumscribed, is also a symp- 
tom of manifold significance which can not be correctly valued 
without thorough investigation. Where the meteorism is circum- 
scribed, we must think of adhesions, or of stenosis, from tumours 
situated either within the intestines or external to them, and partly 
connected with other abdominal organs — in women especially with 
the genital organs. 

3. Constipation 

(a) Acute, chronic, habitual, or periodic. 

(b) If acute, when was the last movement ? 

(c) If chronic, does it alternate with diarrhoea ? 

(d) Duration of the entire trouble. 

(e) Are the movements retarded, or spontaneous, or do they 

occur only after laxatives ? If the last, what is the nature 
of the laxative ? Are enemata employed ? 
Constipation may at times be a harmless condition ; at other 
times it may be extremely severe and dangerous, frequently causing 
death. The first question which presents itself is : Have we to do 
with acute constipation in a case in which up to the present time 
there were normal movements ? Such a condition may naturally 
be brought about by various causes — e. g., sudden change in habits 
of life or in climate, errors in diet, mental excitement, diarrhoeas 
lasting for days and weeks, the administration of opium, * bismuth, 
tannin, morphin injections, or of other drugs which cause temporary 
arrest of intestinal peristalsis. Intestinal occlusion or stenosis may 



* For a long time I have had under observation a female patient who has suf- 
fered from obstinate constipation since an attack of perityphlitis. The cause of 
her constipation is most probably the use of large doses of opium. (Cf. further 
remarks as to this in the chapter on Perityphlitis, Part 11.) 



THE HISTORY 61 

be present, or the constipation may be an accompanying symptom 
of an acute affection of the central nervous system (basilar menin- 
gitis) or an acute lead colic. Here, again, only a careful general as 
well as local examination can demonstrate the true underlying con- 
dition.* 

Where we have to deal with a case of chronic habitual constipa- 
tion, the existence of a functional intestinal weakness (intestinal 
atony), or of an organic condition, will come into question. This, 
again, can only be determined by a detailed examination. Where 
there is constipation lasting for many years and not associated with 
disturbances of the general bodily conditions, one generally thinks 
of " functional intestinal weakness " (atony) or of intestinal catarrh. 
It should never be forgotten, however, that habitual constipation 
and chronic enteritis also predispose to the development of intes- 
tinal cancer with subsequent stenosis (see chapter on Cancer). Even 
at the present day the view so often expressed, that many years' dura- 
tion of a disease speaks against cancer, is only correct when greatly 
modified. The frequent development of cancer upon a coprostasis 
of many years' duration should teach us to be more cautious. Fur- 
thermore, in women we should always examine for some genital 
disorder as a cause of existing constipation (retroflexed uterus, dis- 
ease of the ovaries or of the appendages, etc.). Where the entire clin- 
ical picture is unlike malignant disease, an exact knowledge of the 
duration and the previous treatment are important. Constipation 
is sometimes congenital or inherited (intestinal atony), or it may be 
acquired during earliest childhood. This is important for the prog- 
nosis and the treatment of the case. A knowledge of the nature 
and effect of the various therapeutic measures employed is essential 
for the proper appreciation of the diseased condition. The poorer 
the reaction of the intestines to laxative measures, the more difficult 
the treatment, and vice versa. 

Where constipation alternates with diarrhoea, we must first of all 
decide which is the primary or dominating condition. It is by no 
means easy for a patient who has doctored much, and who has alter- 
nated between laxatives and astringents, to answer this question. 
To appreciate the real functional disturbance, it is best for the pa- 
tient to stop all medication for a few days. Should diarrhoea regu- 

* In this connection it might be remarked that regular movements of the bowels, 
or even diarrhoeas, do not at all exclude intestinal occlusion. Cases with undoubted 
intestinal obstruction have been described in which faecal vomiting as well as the 
passage of wind from below, or even faecal movements, occurred. 



62 DISEASES OF THE INTESTINES 

larly follow constipation, organic stenosis of some kind in some part 
of the intestines, or else an intestinal catarrh, may be present. Here, 
again, without a most careful examination, especially of the rectum, 
it is absolutely impossible to come to a conclusion. Finally, should 
repeated examinations constantly yield negative results, the ques- 
tion of a nervous enteropathy or of hysteria may, with the greatest 
reserve, be considered. 

4. Diarrhoea 

(a) Acute or chronic ; during intervals ? 

(b) How frequently during the day ? 

(c) With or without pain ; if present, its character and situation. 

(d) Does constipation follow the diarrhoea ? 

A sudden attack of diarrhoea may result from a simple error in 
diet, or, on the other hand, may initiate a severe, acute, infectious 
disease (typhoid, dysentery, cholera nostras, and asiatica, ptomain 
poisoning from decayed meats, etc.). In these cases the disease 
presents a number of other symptoms, which, together with the 
objective examination, sooner or later clear up the diagnosis. We 
may, however, have to deal with one of those frequent cases of 
infectious enteritis which originate especially during the summer 
months, from bacterial or other direct local sources (dyspeptic diar- 
rhoea, Nothnagel). 

Chronic recurring diarrhoea occurs as a symptom of organic 
intestinal disease, of local intestinal neuroses (i. e., secretion neuroses, 
reflex neuroses of tabes and other systemic diseases, crises ente- 
riques), or of nervous enteropathies. If the diarrhoea is a symptom 
of the first-named affections, it may be due to catarrh, atrophy, 
ulceration, or amyloid disease of the intestinal mucous membrane. 
In stenoses of the intestine there are generally, every few days, 
watery, pasty, or partially fluid, partially solid stools. Under pre- 
disposing conditions, patients with stenosing, ulcerating carcinoma 
of the ileum may have continual diarrhoeas, usually of a purulent 
character. I have observed and performed post-mortem examina- 
tions on two such cases (for particulars, see Part II of this work). 
Finally, chronic diarrhoeas may occur as a symptom of nephritis 
(urgemic diarrhoea), of the uric-acid diathesis, of congestion in the 
portal system, etc. The symptom "diarrhoea," therefore, is so 
closely connected with apparently widely differing conditions that a 
satisfactory diagnosis of its cause and nature can not be reached 
without a careful general and local examination. 



THE HISTORY 63 

5. Character of the Evacuations 

(a) Consistency, quantity, and colour. 

(V) Pathological admixtures (mucus, fragments of membrane, 
blood, pus, tumour detritus, parasites). 

(c) Odour (feculent or putrid). 

In most eases the physician should not be satisfied with the 
description of the stools as given him by the layman, but should 
inspect them himself, and eventually examine them under the 
microscope. If necessary, a chemical examination should also be 
made. Where the patient's statements are positive, or where they 
can not be personally controlled, the descriptions as given can not 
be entirely ignored, for occasionally the statements are of the great- 
est importance. Sometimes a careful account of the consistency 
and calibre of the stools is of decisive value in arriving at a diag- 
nosis by exclusion. Thus, persistent cylindrical stools of normal 
calibre would generally exclude a stenosis of the intestines. 

Conversely, stools of an abnormally small calibre do not speak 
with any degree of certainty for a stenosis of the intestines ; in 
this case the diagnosis must rest upon the presence of other symp- 
toms. The stools may be pasty, semisolid, or fluid in consistency. 
The first two of these characteristics may be present in the normal 
individual ; the last is always indicative of an abnormal condition 
and calls for a most careful examination. Scybalous stools indicate 
a long retention of the faeces in the haustra coli, and this is a fre- 
quent cause of attacks of intestinal colic (spastic contraction of the 
intestines). 

The patient's statement of the quantity of faeces passed in 
twenty-four hours is generally correct. I say generally, because I 
have often had neurasthenics declare that they have had insufficient 
evacuations, although they actually passed large quantities of faeces. 
In many cases the quantity is not commensurate with the amount 
of food ingested ; this may be due to the kind of food taken (espe- 
cially meat), or to deficient peristalsis. Probably intestinal absorp- 
tion is increased after a period of fasting, so that even normally 
in the first few hours after eating again the amount of undigested 
matter is disproportionate to the amount of food ingested. 

The colour of the movements may vary considerably from the 
normal. The patients are most apt to notice the clay-coloured 
stools that occur with icterus, or sometimes without icterus (see sec- 
tion on Faeces). But since icterus is only a symptom, the diagnosis 



64 DISEASES OF THE INTESTINES 

of the primary trouble is impossible without further knowledge of 
the cause of the disease. 

The pathological admixtures in the faeces which may at times 
be seen and correctly described by the patients are mucus, mucous 
membrane, blood, pus, fragments of new growths, undigested food 
remnants, and parasites. 

Where mucus is present in large quantities, or is passed alone, 
it is usually noticed by observant patients. Sometimes these move- 
ments of mucous membranes are so characteristically described that 
the diagnosis — membranous enteritis (colica mucosa) — is readily 
made. In general the patient's description very seldom yields use- 
ful data. 

Blood may be mixed with the stools, in a fresh fluid or decom- 
posed state. The latter lends an intensely tarry or pitchy appear- 
ance to the stool. However, the description, or even the micro- 
scopical appearance, is decisive only in a very few and these other- 
wise absolutely clear cases (see section on Faeces). It is important 
here to know if symptoms of severe internal haemorrhage (collapse, 
syncope, pallour of the visible mucous membranes, systolic murmur 
at the apex of the heart, etc.) accompany the intestinal haemorrhage. 
The darker the appearance of the blood the more correct are we 
in assuming that the bleeding is located very high up (stomach or 
upper portion of small intestines). Tar-coloured blood comes only 
exceptionally from the lower portions of the intestines. Fluid blood 
comes mostly (but not always) from the large intestine, including 
the rectum. By rectal palpation, or by use of the speculum, it can 
frequently be determined whether the latter is the seat of the bleed- 
ing or not. If the rectum can be excluded, various diseased pro- 
cesses may come up for consideration — acute or chronic dysentery, 
faecal ulcers, tubercular ulcers, tumours of the large intestine (be- 
nign or malignant), and acute or chronic intussusception or other 
forms of intestinal obstruction. 

The admixture of pus with the stools, or the discharge of pus 
from the rectum, is always a striking symptom. The pus may come 
from the rectum itself (ulcerating tumours or ulcers, rectal fistulae), 
or it may come from intestinal segments above the rectum. We 
can only determine the seat and cause of the pus formation by 
means of repeated careful examinations of the entire intestinal 
canal and of the faeces (vide Chapter V). 

The fragments of new growths which may be noticed by the 
patients are broken-off pieces of cancerous tumours (very rare), or 



THE HISTORY 65 

exfoliated intestinal polypi. For obvious reasons, it requires a per- 
sonal examination to pass an opinion upon these. In intussuscep- 
tion, the intussusceptum may become gangrenous and be passed. 

Parasites, especially segments of the tapeworm, may be recog- 
nised by the layman, but may at times be also confounded with a 
number of other things. 

The importance of the presence of food remnants will be dwelt 
upon in the chapter on Faeces. 

The odour of the normal stools is feculent, but not putrid. 
Should it be offensive, however, and should the statements of the 
patients upon this point be very positive, a personal examination of 
the stools and of the intestinal canal may be necessary. Putrid ad- 
mixtures with the faeces are always a serious symptom, and are 
generally due to the breaking down of malignant tumours or of 
ulcers, to abscesses, perforations from neighbouring organs, etc. 

6. Tenesmus 

As a rule, tenesmus indicates an affection of the large intestine. 
Apart from dysentery, which is almost always accompanied by te- 
nesmus, and from acute intestinal catarrh with copious diarrhoea, the 
greatest variety of intestinal disorders come into question when 
tenesmus is complained of. For this symptom may be occasioned 
by excessive coprostasis, more frequently, however, by proctitis and 
periproctitis, rectal ulcers or catarrh, haemorrhoids, prostatitis and 
prostatic hypertrophy, inflammations and malpositions of the uterus, 
ovarian tumours, etc., and, finally, by foreign bodies which have 
entered the rectum from above or below. Especially in children is 
tenesmus a frequent symptom of acute and chronic intussusception. 
The condition in each individual case must be determined through 
inspection and palpation of the rectum and of the rest of the intes- 
tinal canal. 

7. Gastric Disturbances 

It can be readily understood that gastric affections are frequently 
associated with intestinal disturbances. The converse is also true. 
As regards acute intestinal affections, especially those accompanied 
by fever (acute infectious enteritis, perityphlitis, etc.), these require 
no further explanation. Faecal vomiting from ileus need only be 
mentioned in this place, as it will be treated of more in detail in the 
chapter on Ileus in the special part of this work. 

In chronic intestinal diseases, even in those of a malignant nature, 



6Q DISEASES OF THE INTESTINES 

the appetite, as well as the other functions of the stomach, may be 
entirely normal. In intestinal tuberculosis, however, the stomach is 
often affected. Here the fever which is generally present is an 
important factor in decreasing the appetite. Frequently, and with- 
out special cause, a well-marked chronic gastritis may complicate 
enteritis (Einhorn, Biedert, Oppler). On the other hand, however, 
hyperacidity may occur under the same circumstances. Chronic 
constipation may be associated with glandular gastritis. The peri- 
odic vomiting which accompanies intestinal stenoses, especially 
those of a severe type, is very remarkable. With Nothnagel, we 
may look upon this as a " regurgitive contraction." (For further 
details, see chapter on Intestinal Stenoses, special part.) Nausea 
and vomiting may also occur reflexly, or during long-continued 
intestinal colics. 

Continued bilious vomiting is a very important symptom of 
deeply seated duodenal stenosis, and will be spoken of at length in 
the special part of this work. 

8. Subjective Abdominal Sensations 

Patients sometimes declare their main symptom to be a feeling 
of pressure and weight in the abdomen. Occasionally they are able 
to fairly accurately locate the seat of this abnormal sensation. Such 
subjective symptoms are naturally only of value when combined 
with the results of the objective examination. 

9. Peristaltic Movements 

Many patients will state either of their own accord or in reply 
to direct questions that they occasionally or constantly experience 
"a crawling, wormlike sensation," sometimes accompanied by 
severe pain ("peristaltic unrest"). The diagnostic importance of 
this symptom will be discussed in the section on Inspection. 

LITERATURE 

1. Treves. Intestinal Obstruction. German translation of Dr. Arthur Pollak. 
Leipzig, 1888, p. 354. 



CHAPTEE IY 

THE EXAMINATION OF THE PATIENT 

1 . Inspection 

In diseases of the intestines the entire body, inclusive of the ex- 
ternal anal parts and the rectum should be inspected. Since inspec- 
tion of the anal region and the rectum is usually associated with 
palpation of the rectum, it will be considered under that heading. 

After we have inquired into the general physical condition and 
nutrition of the patient, we should inspect his mouth, to ascertain the 
condition of his teeth, his tongue,* and his pharynx. The patient 
is thereupon told to disrobe, and is at first examined in a standing 
position. Any striking variations from the normal should at once 
be noted (colour of skin, scars, growths, spinal curvatures and pro- 
tuberances, or depressions of any part of the chest, etc.). 

Direct inspection of the abdomen should now begin. The 
patient should either lie in bed or upon a good elastic couch, with 
his head extended and the legs and abdominal muscles as fully 
relaxed as possible. The illumination must be good; daylight is 
best, but in its stead we can employ gas or electric light, either 
direct or properly reflected. Like palpation (q. v.), inspection is 
carried on in two ways : during shallow and during deep respi- 
rations. 

As regards the shin over the abdomen, we have here to look for 
striae and venous engorgements. Besides ascites, venous engorge- 
ment of the skin results from new growths of the abdomen when 
these compress the portal system. This condition is not without 
importance in the diagnosis of abdominal tumours which are deeply 
seated and palpable only with extreme difficulty. Inspection also 
enables us to readily detect protrusions or depressions of the abdo- 
men. Protrusions may be localized, or they may extend over the 

* The condition of the tongue in intestinal diseases is of less importance than 
in gastric diseases. On the other hand, bad condition of the teeth may be a defi- 
nite etiological factor in gastric or intestinal catarrhs. 

67 



68 DISEASES OF THE INTESTINES 

entire abdomen ; they may result from abnormal accumulation 
of gas or fluid. We should note small differences in the level of 
the abdominal surface, especially if some segments of intestines 
are more prominent than others. Hernias of the abdomen (umbili- 
cal, linea alba, ventral, femoral, and inguinal) are readily recog- 
nised, especially when the patient coughs. Usually simple palpa- 
tion is all that is required to make the diagnosis. The prominence 
above the general surface of the abdomen of any new growth is very 
important. On deep inspiration we may convince ourselves of any 
mobility of these neoplasms, which is a consideration of great value 
not only for the diagnosis but also for the treatment of the case 
(operation). It appears important to me, therefore, to point out 
that even small new growths are much more readily detected hy care- 
ful inspection with a good light (a very iinportant point) than they 
are through palpation. 

Under especially favourable circumstances (e. g., descensus), and 
particularly where there is a marked coprostasis, it is possible to 
recognise isolated segments of the large and small intestine. We 
find both abnormal abdominal depressions and prominences. Basilar 
meningitis and lead colic present well-known classical examples of 
depressed abdomen. Abnormal depressions also occur in marked 
cachexias, inanition, esophageal and cardial cancers, as well as in 
other non-stenosing growths in the upper portion of the digestive 
track. Much interest attaches itself to visible peristaltic move- 
ments. These normally occur in very emaciated persons, particu- 
larly in women who have frequently borne children (vide special 
part of this work), and are then, as Nothnagel 1 correctly points 
out, limited to the small intestines. Visible peristalsis of the large 
intestine is therefore a pathological condition. It may be an intes- 
tinal neurosis (tormina ventriculi nervosa), as illustrated in a strik- 
ing case which I have recently demonstrated 2 , or may constitute an 
important and, if well developed, a decisive symptom of a chronic 
intestinal stenosis. Since the peristaltic waves are most marked 
above the point of stenosis, we can in a general way determine the 
seat of the obstruction. Besides these forms, which really represent 
but an exaggerated and for the most part a painless type of normal 
peristaltic movement, there is a second form, the tetanic intestinal 
contraction; this varies according to the emptiness or fulness of 
the intestines. As instances of tetanic contraction with empty 
intestines, Nothnagel mentions cerebral meningitis and lead colic. 
He thinks that in rare cases the contracted coils are visible. This, 



THE EXAMINATION OP THE PATIENT 69 

however, has never been my experience ; on the other hand, tetanic 
contractions with filled intestines are more frequent, and constitute 
an exceedingly important diagnostic symptom. One may see a 
rounded elevation suddenly appear in a circumscribed portion of the 
intestine and accompanied by most severe pain, gradually become 
more and more prominent, become rigid, and then suddenly sink 
back again. This is often accompanied by loud gurgling and rum- 
bling sounds and a subsidence of the pain. ISTothnagel 1 has very 
aptly applied the name "intestinal rigidity" to this condition. The 
gradual increase in intensity, the pause at the acme, and the sudden 
subsidence may all be better appreciated by placing the hand over 
the part than by inspection. This form of tetanic contraction 
always points to an obstruction of the intestinal passage ; however, 
it gives us no information regarding the nature of the obstruction 
— i. e., whether within or without the intestinal canal, whether caused 
by a foreign body or by disease of the mucous membrane, etc. The 
causes of "intestinal rigidity" will be referred to in the special 
part of the present work. 

2. Palpation 

A. Palpation of the Abdomen 

The great importance as well as the difficulties of palpation 
have 5 been dwelt upon elsewhere 3 . What has there been stated 
applies to a greater degree, if possible, to the intestines. In the 
following the most important points in regard to the technic of 
palpation are again given. 

1. A good couch, not too soft, and accessible from all sides, 
should be used for the examination (a lounge is preferable to a bed). 

2. The patient should lie in the horizontal position, with the 
head extended and as low as possible. 

3. The legs as well as the rest of the body should be as fully 
relaxed as possible (anaesthetic posture). I have very seldom seen 
any advantage from the drawing up of the lower extremities which 
is still often recommended. 

4. Palpation should be conducted in a warm room, and only 
with warm hands, for otherwise the abdominal walls will contract 
at the slightest touch, and deep exploration become impossible. 

5. The attention of the patient is to be distracted from the ex- 
amination by questioning him regarding his age, heredity, etc., and 
by having him stretch out his tongue, raise his arms, etc. 

6 






70 DISEASES OF THE INTESTINES 

6. Palpation at first should include the superficial portions of 
the abdomen, and only very gradually should the deeper parts be 
explored. 

7. The condition of fulness of the abdominal cavity at the time 
of examination is very important. The distention of the abdominal 
cavity with gas or fluid, of the stomach with food, of the large in- 
testine with fsecal masses, and of the bladder with urine, may at 
times interfere with the examination, but, as will be later shown, 
this is not always the case. We should therefore make it a rule 
never to make a diagnosis at the first visit, but should point out the 
necessity of a further examination after removal of the above-men- 
tioned conditions. 

8. Always palpate in the right and left lateral positions, as well 
as in the dorsal, for frequently growths of the stomach, of the intes- 
tines, or of other organs, can not otherwise be palpated. Bimanual 
palpation is especially to be recommended for the examination in 
the lateral position. 

9. For the better recognition of tumours, enlargements, or alter- 
ations in position of abdominal organs, differentiated otherwise with 
great difficulty, V. Chalapowski, Lennhof, G. See, Schuster, Berk- 
han, and others, have recently strongly recommended palpation in a 
warm full bath. Although I have had no personal experience with 
this method, in spite of its inconvenience, it appears to me to 
possess a number of advantages which would justify a more exten- 
sive trial. 

In palpating the abdomen we may proceed in one of two ways : 
Either fix upon and at once explore some point that attracts atten- 
tion, or examine systematically. The former method is to be rec- 
ommended only to the experienced, while the latter is to be recom- 
mended to the beginner. I would advise the following method of 
procedure : Examination of the abdominal wall for oedema, emphy- 
sema of the skin, excessive fat, lipomata, etc. ; examination of the 
epigastrium, paying special attention to splashing and succussion 
sounds, etc. ; examination of the right and left lobes of the liver, 
the region of the small intestines from the pylorus downward to 
the umbilical region. The hernial canals should be palpated ; also 
the region of the csecum (McBurney's point midway between the 
anterior superior spine and the umbilicus). From the caecum the 
examination is to be continued along the ascending, transverse, 
and descending colon, and the sigmoid flexure. The ascending 
and descending colon are best palpated in the right and left lateral 



THE EXAMINATION OF THE PATIENT 71 

postures respectively. At the same time the condition of the kid- 
neys (dislocation, fluctuation, and tumours) and of the spleen may 
be determined. 

This plan is of course, to a certain extent, schematic, and assumes that the 
intestines are in their normal position. We must, however, reckon upon possible 
anomalies of single segments, especially those of the very mobile portions of the 
large intestines. (Compare further remarks upon this on page 21 et seq., arid also 
the chapter on Displacements of the Intestines, in the special part of this work.) 

Under favourable conditions it is undoubtedly possible to pal- 
pate certain segments of the intestines. Obrastzow 4 , who has thor- 
oughly studied the technic of this subject, has obtained remark- 
able results by palpation. He was able to locate the caecum in 
51.47 per cent of the men and in 58 per cent of the women he 
had examined ; the transverse colon in 23 per cent and the sigmoid 
flexure in 65 per cent of all his cases. Unfortunately these results 
are not accompanied by post-mortem records, and therefore they 
lose much of their statistical value. As pointed out in the oft- 
quoted instructive treatise of Curschmann, the greatest caution must 
be exercised in accepting palpatory results of the large intestines, 
since the latter are so frequently displaced. Nevertheless, we may 
safely assert that the sigmoid flexure is the most easily palpated 
segment, the transverse colon the most difficult, while the caecum 
occupies a position between the two. It is frequently possible to 
palpate the sigmoid flexure and the ascending colon from their be- 
ing filled with scybalae ; upon palpating the lower portion of the 
ileum or caecum, the impression is conveyed as if of a thin pasty 
mass under the fingers, and one can hear and feel the gurgling 
sounds, formerly considered an important symptom of typhoid 
fever. These signs, however, are to be accepted in a diagnostic 
sense only after most careful consideration. Abnormal thinness of 
the abdominal walls and distention of the bowel by faeces render 
palpation of the large intestine much easier. In the presence of 
such conditions, it is, I believe, possible to map out the entire large 
intestine. To determine intestinal displacements it might even be 
advisable to bring about an artificial coprostasis. 

Eecently, Edebohls 5 has claimed that the vermiform appen- 
dix, especially in women, is often palpable, and that from the con- 
dition found one can tell whether in a given case the appendix is a 
normal or an abnormal one. He recommends that one should 
press as deeply as possible toward the posterior wall of the abdo- 
men and floor of the pelvis, keeping to the outer side of the iliac 



72 DISEASES OF THE INTESTINES 

artery. I have never succeeded in satisfactorily palpating the 
appendix. In my experience, it is easier to palpate isolated coils of 
the small intestines, particularly in enteroptosis. 

This, however, is of no practical advantage, for it will rarely be 
possible to recognise what particular segment is felt. I would here 
remark that Obrastzow 6 points out the importance of palpation of 
the ileum for the diagnosis of typhoid, claiming that the gut appears 
thickened, uneven, and painful. 

As in the stomach, so also in special palpation of isolated intes- 
tinal segments the following points come up for consideration. 

(a) Sensitiveness to Pressure ; Pain (Circumscribed or Diffuse) 

We shall first give a few practical preliminary remarks. All 
portions of the intestines are painful upon rough handling, the 
csecal region more so than the rest ; furthermore, owing to the 
adjacent sympathetic fibres, pressure over the large blood-vessels 
causes pain, especially in women whose abdominal walls are relaxed 
from frequent childbirth s, and in very emaciated men. In the 
palpation of isolated intestinal areas of anxious and excited indi- 
viduals I have frequently met with a " pseudo-painfulness." It is 
well to have the painful areas pointed out and to re-examine them 
after a few moments. We can thereby convince the patients them- 
selves of their error. In this connection I wish also to call atten- 
tion to a general hyperalgesia of the abdominal wall not infre- 
quently met with in neurasthenics. 

Practically, we should distinguish between pressure sensitiveness 
and pain. Thus, an acutely inflamed appendix, or, in acute dysentery, 
the sigmoid flexure and the descending colon are painful, whereas 
in chronic enteritis the large intestine is but slightly sensitive to 
pressure. The differentiation of such degrees of sensitiveness must 
be carefully practised and studied. Yery important, too, is the 
differentiation between a localized and a diffuse pressure sensitive- 
ness. In ulcer of the duodenum we meet with a very circumscribed 
area of pain, beyond whose limits pressure made with the necessary 
precaution is absolutely painless ; on the other hand, in appendicitis 
with diffused peri-appendicular abscess the entire region of the 
caecum, or even the entire ascending colon, may be painful on 
pressure. Again, in general peritonitis the entire abdomen is pain- 
ful even to the slightest touch. Multiple circumscribed sensitive- 
ness is found in catarrh of the small intestines complicated by fol- 
licular ulcers (for the most part tubercular) ; it may, however, be 



THE EXAMINATION OF THE PATIENT 73 

absent. "When present, it can, when viewed with a certain amount 
of reserve and in connection with other symptoms, acquire a diag- 
nostic value. I have often observed a diffuse pressure sensitiveness 
in chronic sigmoiditis. This I regard as an important symptom to 
which little attention has been paid. I will refer to it more in detail 
in the chapter on Enteritis (special part). A pressure sensitiveness, 
at first localized, but later diffused, may coexist with malignant 
growths, stenosis from other causes, intussusception, and volvulus. 
Further details of this subject must also be reserved for the special 
part of this work. 

(b) Splashing Sounds (Glwpotage) y Succussion Sounds 

In my experience, intestinal splashing sounds occur only in the 
large intestine, and only under certain conditions. As far as I can 
learn from the literature, this subject has received but little atten- 
tion ; it therefore seems proper to consider it more in detail. A 
certain relaxation of the intestinal walls as well as the presence of 
fluid or thin pasty contents are necessary for the production of 
splashing sounds. Furthermore, the abdominal walls must be suffi- 
ciently yielding, so that the wave of contact may be readily trans- 
mitted to the intestines. Thinness of the abdominal wall and lax- 
ity of the intestines are normally present in women who have borne 
many children. It is different, however, with regard to the physi- 
cal state of the intestinal contents. From the investigations of 
Macfadyen, Nencki, and Siebers (p. 45) we know that normally the 
contents of the lower part of the ileum are of a thin pasty consist- 
ency ; as such they enter the caecum, and there gradually assume 
a firm cylindrical shape. Normally, therefore, a splashing sound is 
never elicited beyond the caecum, or the ascending colon. 

To make certain whether or not substances of pasty consistency can cause 
splashing sounds in the large intestines, I directed my former assistant, Dr. 
Ehrlich, to ascertain whether splashing sounds could be elicited in the large 
intestine after injections of large quantities of thick pasty soups. It was found 
that these sounds could be distinctly elicited in the sigmoid flexure, and in two 
cases in the cascum, and more particularly in the transverse colon. Marked 
liquefaction of the contents of the large intestines is still more favourable for 
the production of splashing sounds ; under such circumstances they may be 
heard even over extensive areas. 

It appears possible, therefore, without special preparation, to 
determine approximately, the position of one or more segments of 
the intestines by means of the splashing sounds. Naturally, this 



74 DISEASES OF THE INTESTINES 

can only be accomplished with normal situation and an absence of 
gastric succussion sounds. 

I was the first to recommend methodical filling of the large 
intestine with measured amounts of water for determination of the 
splashing sounds 7 . This method is somewhat cumbersome, and as 
yet not well known ; it does, however, give us some diagnostic data. 
If after thoroughly emptying the intestines of a healthy individual, 
we allow lukewarm water to flow slowly into the rectum through 
a soft-rubber tube and funnel, all segments of the large intestine 
will gradually fill up. After 500 to 600 cubic centimetres have been 
introduced, a splashing sound, more or less distinct, may be obtained, 
at first in the region of the sigmoid flexure, but later also in the 
transverse colon, and finally in the caecal region. Under favourable 
conditions a slight succussion sound can be heard upon changing 
the position of the body. In marked atony of the large intestine 
we will obtain a splashing sound in the above-mentioned places after 
only 200 to 300 cubic centimetres have been introduced. Should, 
however, the splashing sound be heard at a point other than where 
it normally ought to be (e. g., far below the umbilicus), it would 
indicate displacement of the segments of the large intestine in ques- 
tion. As in the stomach, downward displacement or a dislocation 
of the segments of the intestine frequently coexists with atony. 
J. Friedenwald 8 has also employed this method and confirms its 
diagnostic value. 

Just as we can obtain splashing sounds in the intestines filled 
with water by striking them with the tips of the fingers, so we may 
also readily elicit succussion sounds wherever there is an excessive 
relaxation or a dilatation of the intestinal walls by shaking the 
patients or by having them rapidly change their position. Suc- 
cussion sounds are very readily heard in the sigmoid flexure or the 
descending colon. 

(c) New Growths • F cecal Tumours; Adhesions 

New growths occur in all parts of the intestinal canal, but 
increase in frequency as we go downward. Malignant tumours 
(cancer, sarcoma, lymphosarcoma, tubercular tumours) are met with 
more often than benign tumours (myomata, fibromata, polyps, ade- 
nomata, angiomata, syphilomata, etc.). If in the following discus- 
sion we speak of tumours in general, we nevertheless have the 
malignant new growths principally in view. 

When a new growth is found in the abdominal cavity and ques- 



THE EXAMINATION OF THE PATIENT 75 

tion of its connection with the intestines is raised, we should first 
of all consider all those other organs to which the tumour might 
possibly belong. Palpation alone is generally not sufficient ; other 
methods of examination — the examination of the stomach contents, 
inflation of the stomach and intestines, injection of water, as well as 
other clinical phenomena (urine, blood, and especially examination 
of the genitals) — must be brought to our aid. As in other abdominal 
tumours, in intestinal tumours the position, mobility, size, consistency, 
sensibility, and respiratory mobility, have to be determined. 

As regards the position of a new growth, that is determined in 
the first place by the normal position of the intestinal segment with 
which it is connected. The position will depend very much upon 
the mobility of the intestinal segment in question. For instance, a 
cancer of the pylorus may be found in the region of the caecum, or 
a perityphlitis below the right lobe of the fiver. 

To begin with the small intestines, the duodenum is compara- 
tively firmly fixed, so that its tumours can very seldom cause marked 
alterations in its position. 

Owing to their large and more freely movable mesentery, tumours 
of the jejunum and of the ileum have a somewhat greater mobility. 
As Nothnagel 9 very correctly observes, this may lead to great diffi- 
culty in the differentiation between tumours of the large and small 
intestines. The caecum and the ascending and descending colon are 
the least movable segments of the large intestine, while the trans- 
verse colon and the sigmoid flexure have the widest range of motion. 
In tumours of these segments there will very probably be a disloca- 
tion of the parts. The tumour itself may tug upon the portion of 
the intestine, dragging it laterally or downward ; or else the bowel 
may become distended above the site of the stenosis, and becom- 
ing abnormally loaded, may drag the intestinal segment at first par- 
tially, later completely downward ; finally, in consequence of begin- 
ning emaciation, there may be a relaxation of the fixation bands 
with a resulting alteration in position of the intestinal segments. 

Furthermore, we must distinguish between passive and active 
(manual) mobility. I have found passive mobility of intestinal 
tumours to be rare ; active motion occurs either not at all, or else to 
a very striking extent. The mobility of the tumour will depend 
principally upon whether a ptosis of the bowels has taken place, and, 
further, upon the presence or absence of adhesions. The nature of 
the tumour itself is also very important. Regarding the size of 
the tumour, this, as in the stomach, will vary considerably, accord- 



76 DISEASES OF THE INTESTINES 

ing to the stage of the process. I have seldom observed intestinal 
growths acquire such dimensions as those of the stomach ; usually 
they are very much smaller. Sarcomata and benign growths form 
an exception ; they may reach enormous dimensions. 

The consistency of the growth depends upon its origin and 
malignancv. Cancers are hard and nodular; sarcomata hard and 
smooth, and they not infrequently have a central soft or even fluctu- 
ating area. Benign growths, as well as intussuscepted portions of 
the intestines, are smooth and uniform, while abscesses and cysts 
always impart the feeling of fluctuation to the examining finger. 

The sensitiveness of intestinal growths is likewise subject to the 
greatest variations. They are, perhaps, never entirely painless ; the 
pressure sensitiveness of benign growths is very much less than that 
of malignant ones. Upon the whole, however, no great weight 
need be attached to the degree of sensibility of the intestines. 

All parts of the intestines are more or less movable with respira- 
tion, most so where the intestinal wall is thin, and poor in fat ; on 
the other hand, adhesions of organs directly connected with the 
diaphragm (liver, stomach, and spleen) may have a disturbing influ- 
ence. Very little diagnostic significance attaches itself to the 
respiratory mobility of intestinal growths. The question of exist- 
ing adhesions is best determined under narcosis. 

Fcvcal tumours play such an important part among intestinal 
growths, and so frequently give rise to errors and confusion in 
intestinal diseases, that they require special consideration. They 
may give rise to errors in two ways : first, in simulating new 
growths, and, secondly, in causing existing new growths to appear 
larger than they really are. In such cases, usually, the diagnosis 
can not at once be made ; we should allow ourselves more time and 
observe the effect of internal and external laxative measures. As a 
rule, the consistency of the growth in question will give us a useful 
diagnostic hint. Apart from the so-called enteroliths, f secal tumours 
are generally of a somewhat doughy consistency, and retain the 
impression of the finger, especially after rectal enemata of oil or of 
soap (which tend to soften them). Even after such enemata the 
peripheral portion of the faeces may remain hard (Randkoth) 
and simulate a tumour, notwithstanding that frequent voluminous 
evacuations (Centralkoth) have taken place. This experience, which 
has been that of absolutely reliable clinicians, calls for the greatest 
caution in the determination of the nature of doubtful tumours. 
The situation can usually be determined, especially upon repeated 



THE EXAMINATION OF THE PATIENT ff 

examinations, although a very instructive case described by Noth- 
nagel shows that even then errors can not always be excluded. 
The history, the status, the clinical course, in short, everything in 
Nothnagel's case, indicated cancer of the caecum, while the autopsy 
showed an ulcerative tubercular stricture in the beginning of the 
ascending colon. 

Gersuny 10 believes that the difficulties in diagnosis so often caused 
by faecal tumours have been overcome by the discovery of a peculiar 
symptom which he describes as "the adhesive sign" (Klebesymp- 
tom); viz., if the finger be very firmly pressed upon the faecal mass, 
the intestinal mucous membrane will become adherent to the vis- 
cous faeces, becoming free again when the pressure is discontinued. 
Gersuny states that we can feel the mucous membrane loosening 
itself, and that such a sensation is characteristic of a faecal tumour. 
Hof mokl n could not, however, convince himself of the existence of 
this " adhesive sign," and, like myself, regards the impressibility of 
the faecal tumour as the most characteristic symptom. 

Under favourable conditions adhesions between the portions 
of the intestines may be palpated and recognised as cicatricial 
strands ; more frequently, however, they are suspected rather than 
recognised. 

B. Inspection and Palpation of the Region of the Anus 
and Rectum ; Examination with Rectal Bouoies 

Palpation is the most certain method of acquainting ourselves 
with diseased conditions of the rectum ; in many cases, however, it 
must be supplemented by inspection and the use of bougies. Pal- 
pation of the rectum should be preceded by inspection of the anus. 
The patient is to be examined either in the lateral or in the knee- 
chest position. Personally, for complete examination of the rectum 
and anus I prefer the latter position. With good illumination we 
can inspect external haemorrhoids, fissures, intertrigo, pruritus ani, 
furuncles, phlegmons, external fistulae, etc. At the same time we 
can at once learn whether or not any pathological secretions (blood, 
pus, or mucus) come from the anus. Inspection is best followed 
immediately by palpation. When a patient complains of rectal 
trouble, rectal palpation should never be neglected. It not infre- 
quently happens in very timid or prudish persons, especially women, 
that we meet with opposition, and we should then, quietly but firmly, 
explain the absolute impossibility of forming an opinion without 



78 DISEASES OF THE INTESTINES 

direct local examination. Even in apparently harmless cases I do 
not hesitate to point out the possible existence of serious disease of 
the rectum. This very quickly has the desired effect.* Palpation 
of the rectum is also absolutely unavoidable in other chronic stomach 
and intestinal affections, which at first glance may appear to have 
nothing in common with the rectum. 

In my Diagnosis and Therapeutics of the Diseases of the Stomach 
(Part I, p. 72) I have emphatically stated that we ought never to be 
satisfied with the mere diagnosis " haemorrhoids," but should always 
explore the rectum very carefully. Sometimes a human life may 
he lost through such utterly inexcusable negligence. 

Technic of Rectal Palpation 

As a rule, the examination is conducted in the knee-chest or lat- 
eral position (see above). 

The finger should be well anointed with borovaselin (oil or 
glycerin are less commendable). f The examination itself must 
never be a forcible one, and should consist in gentle rotatory move- 
ments, and where the patient already complains of rectal pain 
should be carried out with particular care. In some cases cocainiza- 
tion of the rectum may be advisable, though I find it can generally 
be dispensed with. 

Passing the examining finger slowly forward, we learn the con- 
dition of the mucous membrane, the presence of foreign bodies or 
of new growths, and the patency of the rectal lumen ; furthermore, 
the condition of the prostate, and in women, such anomalies of the 
sexual organs as can be recognised by palpation through the rectum. 

If the disease process be situated high up, and is entirely inac- 
cessible, or accessible only with great difficulty in either of the two 
mentioned positions, we may reach it with the patient in the dorsal 



* Other circumstances may at times lead to difficulty in the exploration of the 
rectum. Kelsey, the experienced New York rectal specialist, relates the following 
characteristic story: " A foreigner told me, when I proposed it [rectal examination], 
that he had entirely too great respect for me to allow such a thing. My only 
answer was that I had too great respect for myself to treat him without knowing 
what was the matter. That helped, and, " Kelsey concludes," we parted amicably." 

[f To prevent the faecal odour from clinging to the finger after a rectal examina- 
tion, it is a very effectual plan before the " preliminary anointing " to liberally 
scrape ordinary soap under the free edge of the finger nail and between the cuticle 
of the finger and the matrix of the nail. The so-called "finger cots" protect the 
examining finger from infection and faecal smell, and when made of the proper 
thinness do not interfere with the palpatory sense. — Tr.] 



THE EXAMINATION OF THE PATIENT 79 

position and by suitable pressure in the left iliac region. In like 
manner we may succeed with the patient in a standing position, 
when the examiner should be on one knee and support the elbow 
of the examining hand upon the other knee bent at a right angle. 
At the same time the patient should be asked to make strong pres- 
sure downward. 

At the time of the first examination it is very desirable to make 
the digital exploration of the rectum as carefully and fully as pos- 
sible, so that we ascertain all that can be learned through palpation. 

In some cases the introduction of one finger is not sufficient to 
palpate the entire diseased area. For this class of cases Simon, 
many years ago, recommended the introduction of the entire hand 
into the rectum. This procedure, which is by no means harmless, 
can of course be carried out only under general anaesthesia. In 
consequence of the resulting relaxation of the sphincter, one or two 
fingers usually suffice for the exploration, and the entire hand is 
necessary in isolated cases only. In rare cases, however, bloodless 
distention, or even slitting up of the sphincter (sphincterotomia pos- 
terior recti), must be undertaken. Since both of these are usually 
preparatory to operations on the rectum, we must refer the reader 
for further details to surgical text -books. 

Examination under narcosis is also indicated, either where the 
nature of the disease can not be otherwise determined because of 
excessive painfulness of the exploration, or else where the disease, 
being known (e. g., cancer), the determination of its extent, particu- 
larly upward, is attended by great difficulties, or, finally, where new 
growths are barely accessible to the finger. 

If inspection or examination with bougies is also required, it is 
best to proceed with these immediately after palpation. The patient 
is thus spared the excitement attendant on every rectal examination, 
and, what is most important also, the uncertainty of diagnosis. 

Ocular inspection of the rectum is best conducted on an operat- 
ing table, in the lithotomy position, whereby the sacrum lies on a 
level with the examiner's chest. The knee-chest position may also 
be used. The examination should be made with the aid of a suit- 
able speculum. The number of these specula almost equals those 
for the vagina. They are all best described in the catalogues of 
instrument makers. For practical purposes most of them are too 
complicated and clumsy. With the observance of the precautions 
described below, one usually succeeds with a simple Sims's, Simon's, 
or a Czerny's speculum, the latter having given me excellent serv- 



80 DISEASES OF THE INTESTINES 

ice on account of the shortness of the one end. A bivalve specu- 
lum is also very good. With proper illumination, one obtains a 
satisfactory picture of the internal rectum. 

Palpation should always precede the introduction of the specu- 
lum. The presence or absence of faeces in the rectum can thus be 
determined. If present, they must be removed through irrigation 
with lukewarm water or weak lysol solutions, or else manually. 

The introduction of a speculum is very much facilitated by the 
relaxation of the rectum. This is readily accomplished by the knee- 
chest position, in which the abdominal organs fall forward and nega- 
tive pressure in the rectum results ; the latter fills with air and 
its walls stand apart. I have convinced myself that deep inspira- 
tion combined with passing the finger into the rectum very much 
facilitates the passing of the speculum. If the instrument be uni- 
formly and liberally anointed with a fatty substance, its introduc- 
tion will be attended by no difficulty. With a good natural or 
artificial light one can carefully inspect all pathological conditions 
of the rectum. This has recently led Kelly 12 to recommend the 
introduction of cylindrical specula with a uniform diameter of 22 
millimetres and a length varying from 14 to 35 centimetres, and 
furnished with obturators. They are introduced with the patient 
in the knee-chest position. As soon as the speculum has passed the 
sphincter the rectum fills with air, and an entirely unobstructed view 
of the rectal cavity is thus obtained. 

Attempts have been made to illuminate the rectum just as in 
other cavities in the body. J. Leiter, of Yienna, constructed an 
instrument for this purpose 13 , which, however, appears to have 
been put to little practical use. After introducing the speculum 
into the rectum, one may employ either reflected electric illumina- 
tion, or more simply, direct electric illumination. 

Herzstein has lately constructed an instrument which I have 
found very useful for the examination of the rectum (Fig. 11). It 
consists of several metal tubes (A), varying in length from 10 to 34 
centimetres, and furnished with metal obturators {B) for the pur- 
pose of easier introduction. The screw (d) fastens the obturator to 
the metal tube. The illumination is supplied by the well-known 
Caspar electroscope ( C). The longest tubes enable one to reach the 
sigmoid flexure. The field of vision is kept clear of mucous frag- 
ments or faeces by cotton applicators 20 and 35 centimetres long. 
To facilitate the introduction of this instrument I have had the 
obturators made conical, and in order to determine which portion of 



THE EXAMINATION OF THE PATIENT 



81 



the rectum the speculum has reached I have had a centimetre scale 
marked upon the tubes. 

Inspection of the rectum, in the first place, enables one to detect 
acute and chronic inflammations of the mucous membrane. In 
acute cases the mucous membrane has not the normal pale appear- 
ance, but appears swollen and strongly injected ; in chronic inflam- 




Fio. 11. 

mations it appears relaxed, swollen, and velvety, is covered with firm 
mucus, and easily bleeds. With good illumination the follicular 
swellings become distinctly visible. In well-pronounced cases, a 
muco-purulent secretion trickles over the surface. As a rule, these 
inflammations are not primary, but occur in connection with other 
rectal diseases. Furthermore, on inspection one can distinctly see 
ulcerations (faecal, dysenteric, tubercular, gonorrhoeal, hemorrhoidal, 
syphilitic, etc.), and, in children, follicular ulcers. When typically 
developed, these different forms can be distinguished from one an- 
other. Rectal fistulse (internal and external), hemorrhoidal veins, 
polyps and other growths, strictures, etc., can also be seen. Since 
these various affections are treated of at length in the second por- 
tion of this work, we may here content ourselves with this brief 
reference to the subject. 

By bougieing of the rectum and of the parts above, we may 
sometimes learn whether or not that gut and the sigmoid flexure 
are patent. For this purpose we employ either soft-rubber bougies,* 
or else the so-called English [known here in the United States as the 
French sounds] or hard-rubber bougies, or, finally, though more 



* Those with a spiral obturator, as devised by Hahn, are particularly good, be- 
cause they combine great elasticity with firmness. 



82 DISEASES OF THE INTESTINES 

rarely, the so-called Trousseau's sounds, with olive-shaped ivory 
points that can be screwed on and off. The softer the instrument 
employed for diagnostic purposes the less the danger. When 
sounding the rectum for the first time, I use only soft-rubber 
sounds or bougies. The question how far a bougie may be intro- 
duced is very important. Some authorities state that it can not be 
passed beyond the sigmoid flexure. According to my own investi- 
gations this is incorrect, for by abdominal palpation of sounds which 
1 had introduced I have been convinced that, if the colon be pre- 
viously distended by water or air, even soft Nelaton sounds can be 
passed into the descending colon. I purposely employ the word 
can, for our success depends principally upon the sound passing 
through ^elaton's sphincter into the sigmoid flexure. In some 
cases this is accomplished very readily, in others only by the aid of 
one or two fingers in the rectum acting as a guide to the instru- 
ment. Should this last precaution be neglected, flexible instru- 
ments curl up in the wide ampulla or impinge against its walls, 
thus making forward passage impossible. On account of the acute 
bend which the splenic flexure makes at the junction of both seg- 
ments of the colon, passage into the transverse colon, on the con- 
trary, is impossible. 

Bougies and sounds should be thoroughly oiled before intro- 
duction ; the latter procedure must be attended by the greatest 
precaution. All force must be carefully avoided. This rule ap- 
plies particularly to all sounds which are not absolutely soft, for 
during simple sounding of the normal rectum perforations have 
occurred. 

The diagnostic value of rectal bougieing is not great. We can 
not learn more from bougieing, at least of the rectum, than we can 
from digital and ocular examinations. On the other hand, only 
through sounding can constrictions of the sigmoid flexure or of the 
descending colon be diagnosed with certainty. Such examinations, 
however, require the greatest possible care, and I would again recall 
the advantages of the above-mentioned rubber bougies.* A stric- 
ture can he diagnosticated with certainty only when, upon repeated 
examinations, the passage of a sound imparts the impression of its 

* Kuhn, of Giessen, recently devised metallic spiral sounds for the sounding 
of the stomach, pylorus, duodenum, and the large intestine. From these sounds 
he hopes to learn much of value for the diagnosis and therapeutics of the said organs. 
Since no evidences of the merits of this method have as yet been advanced, we will 
not discuss it, nor the method of Hemmeter for the intubation of the duodenum. 



THE EXAMINATION OF THE PATIENT S3 

always having to overcome a resistance at the same point, and 
when, after the suspicious point is passed, the withdrawal of the 

sound also girts one the impression of passage through a narrow 
portion. 

Aside from diagnostic purposes, rectal bougies are also em- 
ployed for the dilatation of strictures. This will be referred to in 
the proper place in the second portion of this work. 

3. Percussion 

In general, percussion gives us less tangible results than palpa- 
tion. Nevertheless it is of value as completing and controlling the 
latter procedure, and it should therefore never be omitted. 

Percussion of the intestines should always be finger percussion, 
never hammer percussion, for with the latter finer distinctions are 
very easily overlooked. We should always percuss lightly, for 
then only, if at all, can differences in tone be clearly brought out. 
In the empty state of the intestines percussion gives the best 
results. It is sometimes of importance to compare the result of 
percussion of the empty with that of the full intestines (and stom- 
ach). Normally, as in the stomach, the percussion note is tym- 
panitic, but varies in pitch in the different segments. On account 
of the descending colon being filled with solid matter, palpatory 
percussion, according to Leo u , almost constantly gives a dull tym- 
panitic tone in the left hypochondrium as compared to that obtained 
on the right side. The diagnostic value of percussion is limited to 
those cases in which we find distinct variations from the normal 
tone. This occurs with free or encapsulated fluids in the abdomi- 
nal cavity, and also in excessive meteorism. The results from per- 
cussion in ascites are so well known that detailed discussion is 
unnecessary. ~SVe wish, however, to speak of the differentiation of 
ail* in the abdominal cavity from that in the intestines. Whereas 
in the former instance the percussion note has everywhere a nni-. 
formly tympanitic sound, and hepatic and splenic dulness disappear, 
in intestinal meteorism the percussion note varies from place to 
place and from time to time. 

The percussion note over large tumours of the intestines I includ- 
ing freeal tumours ) is flat, provided they are not covered by intes- 
tinal coils that contain air. In the presence of moderate amounts 
of fluid in the abdomen, tumour percussion in various postures of 
the patient may also yield useful results. If the abdomen be tapped 
before percussion the results will naturally be more satisfactory. 



84 DISEASES OF THE INTESTINES 

By filling the intestines with air or water we can establish condi- 
tions favourable to percussion (see pages 74 and 85). 

In ileus, in order to distinguish between widely distended intes- 
tinal coils and those of smaller calibre, a few authors, particularly 
Curschmann 15 , have recommended pleximeter percussion. 

4. Auscultation 

Of all physical methods of examination, auscultation has the 
least diagnostic value. It is true that sounds (borborygmi, gur- 
gling, etc.) are heard in the most varied diseases of the intestines, 
but the nature of their production is so atypical that little can be 
learned from them. In stenosis of the large intestines we meet 
with intestinal sounds (especially frequently recurring intestinal 
sounds) on a most extensive scale, but compared with the data 
obtained from palpation, or even inspection, their diagnostic value is 
minimal. On the other hand, the absence of all intestinal sounds, 
together with total absence of all intestinal movements, is of diag- 
nostic value in perforative peritonitis (E. Wagner 16 ). 

The well-known ileo-csecal gurgling of typhoid fever to-day 
possesses an historical value only. All experienced physicians 
agree that it has no practical value. Regarding succussion and 
splashing sounds, compare above (page 73). 

5. Inflation of the Intestines 

Inflation of the intestines can be accomplished either through 
the introduction of mixtures which form carbonic-acid gas (bicar- 
bonate of soda and tartaric acid, von Ziemssen 17 ), or of carbonic- 
acid gas from fluids in retainers (O. Rosenbach 18 ), or else from 
inverted siphons of carbonic-acid gas 19 , or finally through the intro- 
duction of atmospheric air by means of a double balloon bulb, such 
as is used with a spray apparatus (Runeberg 20 ). Of all these meth- 
ods the last mentioned is certainly the simplest and best ; we can 
inflate the intestines with as much or as little air as we wish. 
Should there be any occasion for measuring the amount of air 
introduced, we may employ a syringe of known volume and intro- 
duce the air from this (Damsch 21 ). 

How far can the air be introduced ? Most authors, particu- 
larly von Ziemssen and O. Rosenbach, claim that the air can not 
pass beyond the ileo-csecal valve ; whereas Damsch has shown that 
with slow inflation and the employment of more than one metre 
of air, the valve may be overcome and even the small intestines 



THE EXAMINATION OF THE PATIENT 85 

inflated. In view of similar successful attempts made with large 
quantities of water (von Genersich 22 ) we must at once admit the 
possibility of overcoming the resistance of the valve with air. 
Both methods are very heroic, and have, besides, no advantage over 
the introduction of small quantities of air or water. 

Upon the whole, therefore, we shall have to remember that, as 
ordinarily practised, the introduction of air distends the large intes- 
tine only. 

The technic of rectal inflation is very simple. For this pur- 
pose a soft stomach or rectal tube, or, in case of necessity, even the 
rubber tube of an irrigator, may be used. A well functionating 
double balloon bulb is attached to the tube. Before introducing 
the rubber tube we must see whether there is much fgecal matter 
in the rectum ; if so, it must be removed. Small quantities of fseces 
need not be taken into account. To learn if air passes into the 
intestines, we should auscultate in the left iliac region ; a hissing 
sound made by the entering air can here be distinctly heard. Prac- 
tically it is very important not to inflate the intestines too greatly, 
for finer shades of difference in sound are best appreciated with 
slight inflation. It is often useful to combine inflation of the stom- 
ach with that of the intestine. 

Inflation of the intestines has a threefold practical diagnostic 
signification ; it enables us to diagnose stenoses with a certain 
amount of probability, sometimes even with certainty ; further- 
more, it makes clear displacements of the intestines, especially of 
the movable portions ; finally, it is of value in locating tumours and 
in determining their mobility. 

Regarding the diagnosis of stenoses, we may remark that nor- 
mally, in compliance with physical laws, the entire large intestine 
forms a uniform prominence ; in stenosis of a segment the infra- 
stenotic portion only can be inflated, and will therefore appear more 
prominent, while the supra-stenotic portion will be very little or not 
at all distended. Furthermore, if the inflation be continued, the 
air will return and pass out per anum alongside of the tube, and 
severe pain will be apt to follow. The results obtained from per- 
cussion in intestinal stenoses are also important ; while we still have 
the usual tympanitic sound above the stenosis, we will get a deeper 
and more sonorous one below it, and after all the air has passed 
out both sounds will again be uniform. When the inflated air 
presses upon the stenosed parts it is sometimes possible to hear a 
peculiar long-drawn sound that may also be of diagnostic value. 
7 



86 DISEASES OF THE INTESTINES 

Great as may be the value of this method, for the development 
of which much credit is due to von Ziemssen, it should nevertheless 
be remarked that reliable results are obtained therefrom only in 
very marked stenoses. In these cases, however, the other symp- 
toms of intestinal obstruction are so well characterized, that, after 
all, intestinal inflation should be employed mainly as a confirma- 
tory method. For obvious reasons it frequently gives negative 
results in the beginning of a stenosis. 

A further advantage of the method lies in the possibility of 
diagnosticating, with more or less certainty, changes in the position 
of various segments of the large intestine. If, for example, after 
moderate distention of the large intestine a transverse protrusion 
is seen below the umbilicus, or even immediately above the sym- 
physis, and the same result obtains after repeated examinations, we 
are safe in assuming that a sinking of the transverse colon (colopto- 
sis) has taken place. The sigmoid flexure sometimes becomes en- 
larged or dislocated, or both, so that the greatest difficulty may be 
experienced in differentiating it from the transverse colon. 

Finally, as is well known, in inflation of the intestines we have 
a means of ascertaining with certainty the position of questionable 
intestinal tumours, and of distinguishing between these and tumours 
of other organs (e. g. the kidney), since the latter disappear gradu- 
ally with inflation, whereas the former (tumours of the intestine) re- 
main as perceptible as before. Nevertheless, this symptom can 
only be taken into account where a tumour previously perceptible 
completely disappears. In like manner intestinal tumours may fre- 
quently be very clearly differentiated from those of the liver. 

6. The Injection of Water per Anum 

The injection of water per anum is principally employed to 
locate an intestinal stenosis (Simon), or to establish the relation of a 
new growth to surrounding organs (Minkowski 23 ). In the latter 
case it is well to combine the procedure with inflation of the 
stomach. 

Here, according to Minkowski, the abdominal tumour slips back 
into the position normally occupied by the organ to which it be- 
longs. Here, also, it is frequently well to combine the distention 
of the stomach by air or water with similar distention of the large 
intestine. The recognition by means of distention of a stenosis — 
especially one occurring far down — is based upon the fact that 
under normal conditions 2 to 5 (!) litres can be passed into the intes- 



THE EXAMINATION OF THE PATIENT 87 

tines, whereas in deep stenosis very much less can be introduced. 
This method is unreliable if for no other reason than because the 
toleration of the rectum for quantities of water varies considerably 
(at least according to my experience). The water is introduced by 
means of an irrigator armed with a calibrated tube or else by means 
of a Hegar's funnel. 

7. Test Lavage of the Intestines 24 

By this I mean a uniform irrigation of the mucous membrane 
of the entire large intestine with water, for the purpose of recog- 
nising anomalies of the same (mucus, pus, blood, or even fragments 
of tumours) in the returning water. 

Technic. — The following rules are given for test lavage of the 
intestine. It is best carried out with the patient in the lateral posi- 
tion, the intestines being previously emptied. 1 use a soft-rubber 
tube, not too small in calibre, and from about 70 to 80 centimetres 
in length, armed, as in lavage of the stomach, with rubber tubing 
and a large funnel. The tube is well greased, and after its intro- 
duction into the anus is gradually pushed forward, while the funnel, 
filled with lukewarm water, is at the same time slowly raised. In 
suitable cases — as can be proved by palpation through the abdom- 
inal wall — we are sometimes able to introduce the tube into the sig- 
moid flexure, or even beyond. As soon as marked tenesmus occurs 
(not infrequently after more than a half litre has been introduced) 
the funnel should be lowered, and the water thus siphoned off should 
be carefully inspected and preserved in clean vessels for macroscopic 
and microscopic examination. Normally, the water returns clear, 
or only slightly cloudy from admixture of very minute particles of 
mucus, epithelium, or small particles of faeces. It is very differ- 
ent, for example, in catarrh of the large intestine. Here the wash 
water to a greater or less extent contains large and small shreds 
of mucus. Their quantity serves as a good criterion of the progress 
and the extent of the disease. We have no simple or easier method 
than this for diagnosticating membranous enteritis. This proced- 
ure, which I have used for a long time, has also given me excel- 
lent results in detecting suppurative and ulcerative processes accom- 
panied by haemorrhage. I have often found pieces of exfoliated 
mucous membrane in the wash water, and though I can not speak 
from personal experience, it appears possible to readily obtain in this 
manner fragments of tumours for examination. Where it is desir- 
able to make a microscopical examination, this procedure possesses 



88 DISEASES OF THE INTESTINES 

the advantage of absolute cleanliness, a fact which is very advan- 
tageous considering the offensive smell of faeces. Besides, the isola- 
tion of pathological substances (free from faecal matter) makes the 
microscopical examination much easier. 

8. Electric Trans-illumination of the Large Intestines 

Heryng and Reichmann ^ were the first to employ diaphanos- 
cope for the determination of the limits of the large intestine. 
They used a black elastic intestinal bougie, to the end of which a 
small Edison lamp was fastened. Before introducing the bougie, 
1,500 centimetres of lukewarm water were poured into the rectum. 
By using a lamp of 25 volt amperes (equal to eight standard candle 
power), the contour and course of the transverse colon were dis- 
tinctly mapped out. With the development of the method, Heryng 
and Reichmann hoped it would be possible to approximately deter- 
mine doubtful tumours of the abdominal cavity, but thus far this 
expectation has not been realized. 



APPENDIX 

The Employment of Rontgen Rays in the Diagnosis of 
Intestinal Diseases 

Hitherto the results in general from skiagraphy in the diagnosis 
of abdominal diseases have not been very promising ; especially has 
it been impossible to positively diagnosticate abdominal tumours 
that could not also be diagnosed by the usual methods. On the 
other hand, the location of metallic foreign bodies in the large 
intestines by means of the Rontgen rays appears to me to be very 
plausible. I am convinced that we can see certain portions of the 
large intestine — e. g., the descending colon — and especially dis- 
tinctly recognise the haustra coli. It is therefore not beyond the 
limits of possibility that we should be able to render displacements 
of the intestines visible to the eye. It remains to be seen how 
much more favourable conditions will be created through the intro- 
duction of metallic sounds and the like into the rectum. Since the 
kidney (particularly the left) and the spleen can frequently be dis- 
tinctly recognised by the fluoroscope, it might be possible, under 
favourable conditions, to make the differential diagnosis between 
tumours of the kidney and of the intestine, or of the liver and the 
spleen. 



THE EXAMINATION OP THE PATIENT 89 



LITERATURE 

1. Nothnagel. Die Erkrankungen des Darms u. des Peritoneums. Wien, 

1895, S. 5. 

2. Boas. Verhandlungen des XV. Congresses f. irmere Medicin, 1897, S. 479. 

3. Boas. Diagnostik u. Therapie der Magenkrankheiten, Th. I, 4te Aufl., 1897, 

S. 71 u. f. 

4. Obrastzow. Archiv f. Verdauungskrankheiten, Bd. i, S. 262. 

5. Edebohls. Amer. Journal of the Medical Sciences, May, 1894. 

6. Obrastzow. Loc. cit., p. 274. 

7. Boas. Loc. cit., p. 105. 

8. J. Friedenwald. Med. News, August, 1894. 

9. Nothnagel. Loc. cit., p. 248. 

10. Gersuny. Wiener klin. Wochenschr. , 1896, No. 40. 

11. Hofmokl. Wiener med. Wochenschr., 1896, No. 43. 

12. Kelly. Cited from Centralbl. fur Chirurgie, 1895, p. 961. 

13. R. Lewandowski. Das electrische Licht in der Heilkunde. Wien u. Leip- 

zig, 1892, S. 211. 

14. Leo. Diagnostik d. Krankheiten der Bauchorgane, 2. Aufl., 1895, S. 109. 

15. Curschmann. Deutsch. Archiv f. klin. Med., Bd. liii, 1894, S. 30. 

16. E. Wagner. Ibid., 1886, Bd. xxxix, S. 72. 

17. von Ziemssen. Ibid., 1883, Bd. xxxiii, S. 235. 

18. O. Rosenbach. Berl. klin. Wochenschr., 1889, No. 28. 

19. Schnetter. Deutsch. Archiv f. klin. Med., 1884, Bd. xxxiv, S. 638. 

20. Runeberg. Ibid., Bd. xxxiv, S. 460. 

21. Darnsch. Berl. klin. Wochenschr., 1889, No. 75. 

22. von Genersich. Deutsche med. Wochenschr., 1893, No. 41. 

23. Minkowski. Berl. klin. Wochenschr., 1888, No. 31. 

24. Boas. Deutsch. Aerzte Zeitung, 1895, No. 2 u. 3. 

25. Heryng u. Reichmann. Therapeut. Monatshefte, Marz 1892. 



CHAPTEK V 

EXAMINATION OF THE FAECES 

Preliminary Remarks. — The examination of the faeces is an 
integral factor in the diagnosis of intestinal diseases. We learn 
from it pathological changes in the secretive, absorptive, and motor 
functions of the stomach and intestines, and ascertain the foreign 
substances that are mingled with the intestinal contents. Fre- 
quently also the nature and location of intestinal diseases can thus 
only be correctly appreciated and diagnosticated. The diagnosis of 
entozoa must be made almost entirely from the microscopical 
examinations of the dejections. 

In spite of all this, we are safe in stating that even at the pres- 
ent day clinical examination of the faeces is not universally prac- 
tised. The cause for this is very clear. In the first place, the repul- 
sive nature of the material itself, so disagreeable to the olfactory 
nerves ; then, again, the unpleasant manipulations that the trans- 
port and examination of the material entail upon the layman and 
the physician ; and last, but not least, the fact that faecal exami- 
nations rarely yield decisive diagnostic results. The first two 
objections mentioned are undoubtedly justifiable ; the latter objec- 
tion is also valid to a certain degree. But the principle, solus oegroti 
prima lex esto, should help us to overcome all hesitancy and diffi- 
culties. As regards the diagnostic value of faecal examinations, it 
must be admitted that a single examination is only rarely sufficient 
to make clear the nature of the disease. Still, this applies equally 
well to all other secretions and excretions — e.g., sputum, stomach 
contents, urine, and vaginal secretions. 

In clinics and dispensaries the facilities for macroscopical and 
microscopical examination of the faeces are usually very easily 
arranged. In private practice, on the contrary, it is usually best 
to make the first gross examination in the dwelling of the patient. 
Should we find anything unusual, or should we for any other rea- 
son wish to make a microscopical examination, we can select the 
90 



EXAMINATION OF THE F^CES 91 

parts which, appear pathological, and preserve them in a small wide- 
mouthed bottle with a glass stopper. Only where exact chemical 
analysis (perhaps for nitrogen or fat) is required, will large quanti- 
ties of faeces be necessary. In some cases — for instance where we 
suspect amoebae — it is very desirable to examine the faeces fresh and 
at the body temperature, if possible. This is readily accomplished 
by warming the bedpan and bringing the material into a bottle, also 
warmed, and wrapped for safety's sake in cotton. If we have an 
incubator we can place the material in it until we are ready to make 
the examination, otherwise some artificial means for maintaining the 
warmth of the faeces can easily be devised. In some cases it is inter- 
esting to follow the development of gases from thin stools placed in 
a warm atmosphere, and to note the influence exerted by certain 
internal medication upon such gaseous formation. For this pur- 
pose we may use the so-called "fermentation tubes" of Einhorn 
and Fiebig, such as are also used in determining the gases of the 
stomach contents. Should we have to deal with ulcerative processes 
of the rectum, we can obtain the secretion directly upon a glass rod 
or a platinum loop — best with the use of a speculum and good illu- 
mination. 

From what has been said, it will be readily seen that the exami- 
nation of the faeces is divisible into the macroscopical, the micro- 
scopical, and the chemical. 



1 . The Macroscopical Examination 

In the last chapter a few striking changes were briefly men- 
tioned and their diagnostic importance dwelt upon. This was 
necessary because, notwithstanding the best intentions, we can not 
at the time of the first consultation always obtain test material, and 
for the time being are compelled to rely upon the statements of the 
patient. In the following discussion it is intended to give as com- 
plete a review as possible of the macroscopical changes of the stools. 
Consistency and form, appearance, quantity, colour, smell, as well as 
abnormal ingredients, will have to be considered. 

^Normally, the faeces are cylindrical in form, with great variations 
in the calibre of the individual cylinders, or else they are homoge- 
neous, and of a thick, pasty consistency. This difference in con- 
sistency depends, among other things, upon the mode of life of the 
individual and upon the nature of the diet. Under certain condi- 
tions variations from the types just mentioned may still be normal. 






92 DISEASES OF THE INTESTINES 

This fact, often overlooked, is of great practical importance. The 
following will serve as an example : A patient who has just passed 
through typhoid fever is constipated. The evacuations occur only 
after enemata, and resemble the normal faeces of the sheep (" schaf- 
kothartig"). In view of the careful diet of reconvalescence, and 
the lack of exercise which is necessarily associated with a cured case 
of typhoid, such a condition of the stools is entirely physiological, 
and it would be a mistake to speak here of atony of the intestines 
following typhoid. Cases like this occur almost daily, and where 
constipation and changes of the stool are complained of, it behooves 
the physician to inquire carefully into the manner of living, and 
above all into the diet of the patient. Conversely, the occurrence 
of diarrhoea with a diet consisting for the most part of milk or of 
milk preparations, or after unaccustomed drinking of sour wines or 
j>artaking of too much fruit or sweets, is an entirely normal condition. 

Since we have frequently observed false therapeutic measures 
instituted because of a failure to properly recognise the conditions 
in question, we believe it best to state these facts, which, without 
doubt, are known to the experienced physician. Variations in con- 
sistency admit of two possibilities : the stool may either be abnor- 
mally hard and passed in small lumps (scybala, "sheep stool," 
"hazel-nut" stool), or in long, thin cylinders ; secondly, the opposite 
condition may occur — the stools are passed in a thin, pasty, or even 
fluid state. 

Yery hard faeces with occasional furrows (evidently impressions 
from the taeniae coli) indicate only long retention within the intes- 
tine, and consequent desiccation. Such an appearance speaks for 
intestinal stricture as little as does the so-called lead-pencil stool. 
In these cases there are, very probably, spastic contractions of the 
intestines, such as are often observed in chronic constipation. I 
would lay more stress, however, upon a different form of stool, 
which I have frequently seen in stenoses of the intestine. This 
consists of a homogeneous, thick, pasty, or curdlike evacuation, in 
which several short cylinders, of the thickness of the small finger, 
float about. The diagnostic importance of this stool formation must 
not be overestimated, and only repeated observation of the same 
condition is of significance. 

Thin stools may also vary in two ways : they may be very watery, 
as in cholera nostras, or asiatica, or they may have a certain admix- 
ture of mucus, which can be easily recognised, since it clings 
to the sides of the glass when the contents are poured out. The 



EXAMINATION OF THE FAECES 93 

microscopical and chemical examinations confirm the presence of 
mucus. 

The quantity of stool passed is seldom of any practical impor- 
tance. In stools of firm consistency the quantity voided is impor- 
tant, if it remain considerably below the normal. It should be 
remarked, however, that depending upon the nature of the diet 
(vegetable, animal, mixed, milk, soup, starvation, etc.) the greatest 
variations occur. There may be repeated small watery evacuations, 
accompanied by marked tenesmus. Such evacuations indicate in- 
flammatory processes in the lowermost segments of the intestine. 
Among other conditions, stools of this kind occur very frequently 
with hemorrhoids, in acute and chronic dysentery, proctitis, inflam- 
mations of the prostate, rectal carcinoma, etc. 

The colour of the feces bears a certain relation to the con- 
sistency. Even the normal colour may show variations ; thus in 
purely meat diet it is dark brown (from hematin and ferrous sul- 
phate) ; in a mixed and vegetable diet, although much lighter, it is 
still brown from urobilin (according to Fleischer 1 , also Mliprasin); 
it is lightest of all where the diet consists mainly of milk. The 
longer the stool remains in the intestines the firmer will be its con- 
sistency and the darker its colour. Under these conditions it may 
even assume a tarlike appearance, which I know has led inexperi- 
enced persons to believe there have been gastric or intestinal hem- 
orrhages. Where the intestinal contents pass rapidly through the 
canal, bilirubin may appear unaltered in the stools ; in fact, some 
stools give bilirubin reaction only. As a result of the absence of 
reduction of the bile pigments, we frequently find unaltered bile 
pigments in children's stools. In itself, a green colouration of 
stools is by no means indicative of bilirubin, for substances contain- 
ing chlorophyl, when partaken of in large amounts, colour the 
feces green. Besides these, there are other alimentary colour 
changes in the stool that are not without practical significance. 
Thus the stools are coloured more or less of a brownish red by 
cocoa, a dark brown with a shade of green by huckleberries and 
preparations containing them, and also, though not so intensely, by 
red wine. Iron and manganese salts give to the stools a darker 
shade than they ordinarily have. According to Quincke 2 , in this 
case the iron is not converted into a sulphate, but, owing no doubt 
to the action of intestinal bacteria, the iron salts are reduced to iron 
oxydyl. Similarly, bismuth colours the stools very darkly, though 
by no means a jet black. As Quincke has recently shown, and as I 



94 DISEASES OF THE INTESTINES 

have been able to confirm through numerous control observations, 
the cause of this is not the formation of bismuth sulphate, but, like 
the iron, the bismuth is reduced to bismuth oxydyl. Calomel fre- 
quently, though by no means always, imparts a greenish tinge to the 
stool. According to examinations of Hoppe-Seyler and Wassiljeff, 
this results from a reduction of a portion of the bilirubin to urobilin. 
The anti-fermentative action of the calomel depends apparently upon 
this change. Besides the drugs mentioned there are many others 
which also cause colour changes in the stools ; thus senna, santonin, 
gamboge, rhubarb and its preparations, colour the stools yellowish. 

Acholic stools are very characteristic, and, in view of the phenom- 
ena attending their appearance, can not fail to be recognised. Owing 
to their importance they will be considered in a separate section, to 
which the reader is referred (see page 103). 

The normal odour of the stool results from the presence of ska- 
tol, and to a lesser degree also of indol. Under pathological con- 
ditions the odour depends largely upon the nature of the sickness, 
and, furthermore, upon the length of time that the faeces have re- 
mained within the intestinal canal. As a rule, the longer they stag- 
nate in the large intestine the stronger will be the faecal odour; 
conversely, after a rapid passage the odour may be very slight or en- 
tirely absent. The rice-water stools of cholera asiatica and nostras 
are the best examples of the last-mentioned condition. In very 
acute intestinal catarrhs and dysentery the odour may be very 
slight or entirely absent. In chronic catarrh of the small intestines, 
too, I have noticed entire absence of any odour. The stools of 
nursing babies often have a sour and slightly faecal smell. The 
evacuations of adults containing large amounts of fat, particularly 
milk fat, may lack the faecal odour, but instead take on an offensive 
smell like fatty acids or even cheese. In amoebic enteritis the faeces 
have a peculiar gelatinlike odour. This was first observed by Quincke 
and Roos 3 , and later confirmed by myself 4 . 

Closure of the common bile duct is frequently attended by obsti- 
nate constipation, and, as a consequence, the evacuations smell very 
strongly ; this condition, however, changes upon the administration 
of agents which increase intestinal peristalsis. Fetid-smelling evac- 
uations occur in ulcerating carcinoma of the large intestine or of 
the rectum, etc. 

Abnormal admixtures in the stool occur very frequently, and at 
times may constitute invaluable diagnostic symptoms of the existing 
intestinal disease. 



EXAMINATION OF THE FAECES 95 

Blood. — Fresh unclotted blood, when mixed with the stool, must 
come from the lower portion of the intestines. It will require local 
examination of the rectum or lavage of the large intestines to 
determine its exact source. Blood may also appear altered and 
decomposed, and impart a colour of tar or wagon grease to the evac- 
uations. We have already stated what is most important in this 
connection on page 64. 

Pus. — Pus may appear with the dejections and be recognised 
by the naked eye. It almost invariably comes from the lower por- 
tion of the intestines, for pus from the higher parts, unless voided 
in very large quantities, is mixed with the fseces, and undergoes 
physical and chemical changes which make it macroscopically and 
microscopically unrecognisable. 

The appearance of mucus in the stools is of special importance. 
Its significance in the diagnosis of intestinal diseases, and especially 
of intestinal catarrh, has been taught us by NothnagePs classical 
studies 5 . Although in what follows I base my remarks mainly on 
Nothnagel's teachings, I differ with this clinician in a number of 
important points, and shall discuss the subject in the light of my 
own quite extensive experience. In the first place, it must be 
remembered that in itself mucus represents a normal product, inas- 
much as it is always possible with chemical reagents to demon- 
strate its presence in the stools.* The mucus covering, which is 
found in very minute quantities partly upon the surface of the 
faeces and partly mingled with them, is also a normal constituent, 
being no doubt only a cohesive agent. Hence I can not indorse 
the statement of Nothnagel, that every macro- and microscopically 
recognisable admixture of mucus with the stool indicates a change 
from the actual physiological condition. 

Even after a single administration of an active cathartic like 
castor oil we frequently find a large amount of mucus in the 
evacuations. We can not here speak of a pathological condi- 
tion. Furthermore, we know that there is a physiological or, 
more properly speaking, alimentary constipation and diarrhoea (see 
above, pages 95 and 96). And here also we can not without 
definite reason regard mucous admixtures in the stools as patho- 
logical. Apart from these restrictions NothnagePs view is fully 
correct. 



* On the other hand, Hoppe-Seyler's view that the main ingredient of all faeces, 
normal as well as abnormal, is mucin, is certainly not correct. 



96 DISEASES OF THE INTESTINES 

Macroscopically recognisable mucus appears under four differ- 
ent forms : 

1. As pure, thick or glistening mucus which is voided as such — 
i. e., unmixed with the faeces. This points with certainty to a dis- 
eased condition of the lowermost segments of the intestines — the 
rectum, or, at most, the sigmoid flexure. It should, however, be 
remembered that absence of such mucus does not at all speak 
against catarrh of the lower intestinal segments. 

2. As mucous shreds, or membranes with or without amorphous 
mucous masses, indistinguishable from that just described. It occurs 
with any of those intestinal affections so frequently referred to, 
which we designate as membranous enteritis ; these will be spoken 
of more in detail when we come to the description of this affection 
in the special part of this work. 

3. As tenacious, sticky, gummy, brownish-yellow mucus, inti- 
mately mixed with thin pasty faeces. If stirred with a glass rod it 
adheres in dense, sticky masses, and is separated from the basic 
mass only with great difficulty. 

4. As small shreds of mucus scarcely macroscopically visible. 
These shreds are best seen by shaking up the faecal mass in a glass 
vessel. 

With the exception of the variety that accompanies membranous 
enteritis, and which at times develops in nervous individuals (colica 
mucosa, Nothnagel), all the other forms indicate catarrh of the large 
intestines. 

Although for years I have carefully looked for those frog- 
spawn or sagolike bodies in the stool whose vegetable origin was 
first recognised by Yirchow, and which are mentioned by Noth- 
nagel in the above investigations, I have thus far never seen them 
in typical form. Kitagawa, on the contrary, thinks that sagolike 
bodies of mucous character are met with in enteritis and in intes- 
tinal ulcers. Research into this matter is not yet concluded, though 
if for no other reason than their rarity these bodies can have but 
slight diagnostic interest. 

Mucus in the form fisrt observed and described by Nothnagel 
as yellow mucous granules is barely visible macroscopically. As 
described by this author, these bodies consist of yellow or brownish 
yellow or even of dark green granules varying in size from poppy 
seeds to peas, and having the consistency of butter. Microscopical 
and micro-chemical examinations have shown that their colour is 
due to unaltered bilirubin, and it can be readily demonstrated that 



EXAMINATION OF THE FAECES 97 

the ground substance of these bodies consists of mucin or of a body 
similar to it. According to JSTothnagel, these bodies point to catarrh 
of the small intestines. They may occur in the stool singly or in 
large numbers. Although I make it a rule to examine the stools in 
every case of intestinal catarrh, I have never seen these yellow 
mucous granules. One of our best authorities upon mucoid bodies 
(Ad. Schmidt) also questions their existence and their diagnostic 
significance. According to Nothnagel, mucus can be recognised 
by the microscope exclusively, only under the following condition : 
Where the faeces are formed, are of a firm pasty consistency, and 
have intimately mixed with them numerous small particles of 
mucus, which appear under the microscope as small homogeneous, 
hyaline, grayish-white refractive islets. Nothnagel regards their 
presence as indicative of a catarrh of the uppermost portion of 
the large or of the lowermost portion of the small intestine. I 
have never seen these hyaline mucous " islets " of Nothnagel, and 
Ad. Schmidt 6 , who regards them as dead amoebae, doubts their mu- 
cous structure. At all events, no positive diagnostic importance 
can be attributed to their presence in the faeces. 

Important as is the appearance of mucus in the stools for the 
diagnosis and location of a catarrh, its absence does not, as I have 
already remarked, exclude catarrh. For example, as Nothnagel 
mentions, and I, too, have been able to show in a very typical case 
(see Part II, Intestinal Catarrh), mucus may be entirely absent in 
jejunitis. Furthermore, mucus may be entirely absent in intestinal 
atrophy — so-called lienteritis of old persons. In both these in- 
stances the clinical picture is so typical that with careful observa- 
tion the diagnosis should present no difficulties. Undigested food 
remnants are visible in the faeces. The opinions even of scientific- 
ally educated and experienced physicians differ so widely regarding 
the significance of this, that I desire to state my own views on the 
subject. 

Per se isolated or occasionally macroscopically recognisable 
food remnants in the faeces do not indicate disease, for they may 
result from poor preparation of the food or from insufficient chew- 
ing ; or else, owing to ntter insolubility, these remnants may have 
entirely escaped the action of the digestive juices. To judge from 
my own experience, this would apply almost entirely to vegetable 
substances (fruits, potatoes, legumes, etc.). Macroscopically visible 
remnants of meat, on the contrary, point to a serious disturbance in 
the function of the digestive tract, the exact location being only 






98 DISEASES OF THE INTESTINES 

possible through the entire clinical observation, especially in com- 
bination with the examination of the stomach contents.* 

The constant appearance of large amounts of the above-named 
vegetables in the faeces points with great probability to anomalies 
of secretion in the gastro -intestinal canal. In particularly severe 
cases of chronic intestinal catarrh in which the stomach, as a rule, 




/■>". \ 




■.',:,. .■■-', 







^ 
-£ 




Fig. 12. — Spirals of Undigested Meat Fragments in Faeces. (Natural size.) 
5, pieces of bronchi. (Original observation.) 

is also involved, we may regularly find large amounts of undigested 
meat, as well as of vegetables, fruits, etc., in the faeces. These sub- 
stances may take on an extraordinary appearance, such as shown in 
Fig. 12, drawn from a fresh specimen. This important form of 
enteritis will be again referred to in the special part of this work. 



* [Recently, in a very interesting and instructive paper, A. Schmidt (Deutsche 
med. Wochenschr., 1899, No. 49) has sought to formulate the principles which 
govern the appearance of meat remnants in the faeces. By experiments he shows 



EXAMINATION OF THE FAECES 99 

Occasionally, fragments of new growths (polyps, ulcerated carci- 
noma, etc.) are seen, although their appearance in the faeces is usu- 
ally accidental. As is well known, entozoa (ascarides, segments of 
tapeworm, oxyuris, anchylostomum, trichocephalus, anguillula, etc.) 
as well as echinococcus are sometimes also found in the stools. The 
diagnostic importance of these bodies requires no special mention. 

2. The Chemical Examination 

The practical object of this book prohibits us from describing 
all chemico-physiological tests. In the following, therefore, we 
treat only of the more important methods, and at the same time 
shall discuss the diagnostic importance of each. We shall consider 

1. Reaction of the Faeces 

The normal reaction of the faeces is neutral or slightly alkaline, 
changing to feebly acid only when the diet is largely a vegetable one. 
The reaction becomes very strongly acid on occlusion of the flow of 
bile into the intestines, being principally due to the presence of fatty 
acids which have been incompletely or not at all saponified. The 
qualitative test of the reaction of the stool is made in the usual 
manner with litmus paper. It should be remarked, however, that 
the surface of the faecal masses may give a different reaction than 
the inner portions. To make a quantitative determination, 20 to 50 
centimetres are mixed in a mortar with about ten times their amount 
of distilled water, and a few drops of ^ phenolphthalein solution or 
of a good litmus solution are added as an indicator ; or litmus paper 
itself may be used instead. Decinormal NaOH or decinormal 
Ba(OH) 2 (Rubner) are added drop by drop until a neutral reaction 

that the connective tissue is digested by the gastric juice and the muscle fibres and 
nuclein by the pancreatic juice. The ingestion pro die of about 100 grams of 
finely chopped and lightly fried beef should result in no meat remnants in the 
stools. From his researches Schmidt concludes : 

1. That the appearance under such circumstances of macroscopically visible 
connective tissue (or of a large amount under a free diet) indicates some disturb- 
ance of gastric function (either secretory, i. e., hyper-, sub-, or anacidity, or else 
motory, i. e., hyper- or snbmotility). 

2. If, in addition to the connective tissue, there are also macroscopically visible 
muscle fibres present, there must also be a disturbance of intestinal digestion. 

3. If visible muscle fibres appear without any connective tissue, there must be 
a serious disturbance in intestinal digestion, but whether dependent upon 
anomalies of the pancreatic secretion or upon interference with the secretory or 
absorptive functions of the intestine itself, it is impossible to state. — Tr.] 



100 DISEASES OF THE INTESTINES 

is obtained. The amount of alkaline solution added to obtain neu- 
tralization can be expressed in percentage, as is done with the stom- 
ach contents. For example, if it requires 3 centimetres to neutralize 
50 grams of fresh faeces, the percentage acidity of the latter will 
be equal to 6 decinormal ISTaOH. Conversely, the alkalinity may 
be determined in suitable cases with decinormal HC1. 

As JSTothnagel has pointed out, no diagnostic significance attaches 
itself to the reaction of the intestinal evacuations. 

2. Determination of Albuminoid Bodies in the Fjeces 

The albuminoid bodies which may occur in the faeces are mucin, 
albumin, and peptones (albumoses). 

(a) Determination of Mucin 

Either the faeces themselves or some mucoid masses mixed with 
them may have to be analyzed. In the first instance the faeces 
should be rubbed up with water, and an equal volume of lime- 
water added ; after the mixture has stood for several hours the 
filtrate is to be tested for mucin. Where mucoid bodies themselves 
are to be analyzed, they should first be dissolved in weak potas- 
sium or sodium-hydrate solution and then tested with acetic acid. 
Insolubility in an excess of the acetic acid would speak for mucin. 
To avoid conf usion with mucinlike nucleo-albumin, the precipitate 
must be further tested by boiling with dilute mineral acids. 
Should a substance which reduces oxid of copper be readily thrown 
down, the precipitate may be regarded as being mucin. It must, 
however, be shown that, after repeated reprecipitation, the sub- 
stance in question is still free from phosphorus. 

A much simpler and an equally effective test, in my opinion, 
is the macroscopical staining of the mucus by means of Ehrlich's 
triacid solution. A small piece of mucus is broken up in sublimate 
alcohol and allowed to stand a short time ; the sublimate solution 
is then replaced by distilled water, and a few drops of triacid solu- 
tion added. If the fragments are coloured green, they are com- 
posed mostly of mucus, and if red, there is an excess of albumin 
(Ad. Schmidt 6 , Pariser 7 , J. Kaufmann 8 ). The diagnostic impor- 
tance of mucus has already been dwelt upon. 

(b) Determination of Albumin 

In testing for albumin in the faeces, the latter are to be extracted 
with a large amount of water to which a trace of acetic acid has 



EXAMINATION OF THE FAECES 101 

been added, and the watery extract filtered a number of times. 
The filtrate should then be tested with the same reagents as used 
in testing the urine for albumin ; of these, acetic acid and ferro- 
cyanid of potash are particularly to be recommended. For the 
quantitative determination of the albumin, Magnus Blauberg 9 
recommends the following procedure : 3 to 5 grams of dried fasces 
are repeatedly (three or four times) digested in ten times their 
volume of thymol water * (each time for three or four hours), and 
the clear supernatant fluid filtered each time through the same 
filter. To these combined filtrates are added one half their volume 
of a saturated solution of sodium chlorid and an excess of Dragen- 
dorf's tannin mixture (tannin, 20 grams ; glacial acetic acid, 37.5 
grams). After a while the filtrate that forms is brought upon a 
previously washed filter, then dried, and the amount of nitrogen 
determined by the well-known Kjeldahl method. In typhoid diar- 
rhoeic evacuations and in two cases of acholic stools von Jaksch 10 
found demonstrable quantities of albumin. 

(c) Determination of Albnmoses and Peptones 

Yon Jaksch n employs the following method : The faeces are 
mixed with water until they have acquired a thin, pasty consis- 
tency ; the mixture is then boiled, filtered while still hot, and the 
clear filtrate tested for albumin with acetic acid and ferrocyanid 
of potash. Usually a slight cloudiness follows the addition of 
the acetic acid (mucin), and does not increase upon addition of 
the potassium ferrocyanid. If such be the case, the mucin must 
be precipitated by a solution of acetate of lead and the filtrate 
further treated with phospho-tungstic acid. The fluid which finally 
remains should be tested for the biuret reaction (caustic soda and 
copper sulphate). If, after the boiling, albumin is still present, it 
must be removed by combining it with acetic oxid of iron, and we 
then proceed in the above-described manner. Magnus Blauberg 9 
simply precipitates the combined watery extracts of the fseces with 
phospho-tungstic acid, collects the precipitates which he dilutes 
with water, and then carefully floats caustic soda and very weak 
solution of copper sulphate upon it (biuret test). To separate albu- 
moses from peptones, the former should be removed by " salting " 
them out with ammonium sulphate. 

* Made by shaking distilled water with a saturated alcoholic solution of thymol 
for a long time, and then filtering. 

8 



IQ2 DISEASES OP THE INTESTINES 

In normal stools von Jaksch never found peptones. In patho- 
logical stools lie found them under most varying conditions — fre- 
quently in typhoid fever, and wherever much pus was produced 
(dysentery, tubercular ulcers, and peritonitis, with rupture into the 
intestines). In affections of the liver the relations were extremely 
varied. In the stools of nurselings Blauberg almost constantly 
found protein substances. 

3. Determination of Carbohydrates in the Faeces 

Hoppe-Seyler 12 recommends the following procedure for the 
determination of carbohydrates : The faeces are distilled, the residu- 
um extracted with alcohol and ether, the extract boiled with water, 
then filtered, the filtrate partially evaporated, and then tested for 
reducing substances by boiling with dilute sulphuric acid, supersat- 
urating with caustic soda, and then adding sulphate of copper solu- 
tion. If we wish to test for sugar, the faeces should be extracted 
with water, the albuminoid bodies in the extract precipitated with 
acetate of lead, the solution freed from lead by means of a current 
of C0 2 , then filtered, and the filtrate tested for sugar by Tro ta- 
mer's or Nylander's test, etc. The quantitative determination of 
sugar is made with dried faeces, after the manner of Allihn and 
Li eb maim. 

It has been already stated (page 38) that the carbohydrates 
are more completely digested and utilized than any other variety 
of nutritive substances. This accounts for their being so constantly 
absent (at least in large quantities) from the faeces. In numerous 
examinations of watery extracts of the faeces, I have only twice ob- 
tained a distinct Trommer reaction ; with Lugol's solution I have 
never obtained a reaction. 

4. Determination of Fats in the Faeces 

For the determination of fat it will, as a rule, be sufficient to 
shake the faeces with large amounts of ether until nothiag more can 
be extracted, and then to evaporate the ether over a water bath. 
The ether takes up only the neutral fats and the fatty acids, but not 
the soaps. The latter are demonstrated by splitting up with acids 
and then extracting with ether. For the quantitative determina- 
tion of the total amount of fat in the stools as should be made, and 
as are indispensable in careful examinations of the so-called " fatty 
stools," we must first estimate the amount of the neutral fats and the 
fatty acids, then the fatty acids alone, and from the difference we 



EXAMINATION OF THE FAECES 103 

learn the amount of neutral fats. Finally, through the agency of 
acids, the fatty soaps in the remainder of the first portion are split 
up into fatty acids, and as such are directly estimated. It would 
lead too far to enter into a detailed description of the methods in- 
volved in these examinations. To those who wish to better acquaint 
themselves with them we recommend Fr. Muller's Studien uber 
Icterus, Zeitschrift fur klinische Medicin, Bd. xi, S. 45-113, and 
von Noorden's Beitrage zur Lehre vom Stoffwechsel, Heft 1, S. 
109 u. f., Berlin, 1892.^ 

In addition to the fixed fatty acids, volatile ones — succinic, 
butyric, propionic, acetic — also occur. They are isolated, and deter- 
mined by fractional distillation. For details the reader is referred 
to the works of Hoppe-Seyler — Thierf elder, Hammarsten (Hand- 
buch der Physiologischen Chemie), and von Jaksch (Klinische 
Diaguostik, p. 280). No diagnostic significance attaches itself to 
the determination of the volatile fatty acids. 

Normally, fat, especially when taken in large quantities, may 
appear with the fasces. It is met with partly as free fat, in the 
form of fatty acids, and partly as soaps of calcium and magnesium. 
A good example of the limitation of fat assimilation is found in the 
taking of large quantities of olive oil, such as are at present em- 
ployed in cholelithiasis. In these cases we may frequently find in 
the fasces fat in lumps varying from the size of peas to hazel nuts ; 
but when taken in a form difficult of solution (pork, mutton, tal- 
low, etc.), it will appear in the dejections even though the amount 
partaken of be small. We speak of fatty stools only when the 
fasces are so loaded with fat that this is even macroscopically visible. 
This variety of stools has a light silver-grayish appearance, and if 
allowed to stand in the cold, especially after being previously stirred, 
two layers — a lower waxy yellow and a faecal one — will form. In 
other and less marked cases we will still be able to recognise fatty 
particles or yellowish translucent fatty plaques, which may be 
isolated for further examination. 

A priori, it is evident that fatty stools may result from two 
causes : either an incomplete absorption of fat well split up and 
saponified, or an insufficient splitting up, whereby its absorption 
into the lymph and chyle channels is rendered difficult. Finally, 
both causes may act simultaneously. There can be no doubt what- 
ever as to the occurrence of the first possibility. Biedert 13 and 
Demme 14 have shown this in catarrh of the small intestines in 
children, and Fr. Muller 15 in adults with caseation of the mesen- 



104 DISEASES OF THE INTESTINES 

terial glands. According to JSTothnagel,* fatty stools occur also in 
atrophy, amyloid disease, and tuberculosis of the intestines. 

It is more difficult to explain the second cause of fatty stools — 
i. e., anomalies in the splitting up of the fat which result from 
pancreatic disease or from insufficient excretion of bile. Although 
the investigations of Abelmann 16 and Minkowski have shown that 
in animals after extirpation of the pancreas absorption of fat no 
longer occurs, control investigations of Sandmeyer 17 and Teich- 
mann 18 have also shown that, in spite of exclusion of the pan- 
creatic secretion, absorption of fat will still take place. In two 
cases of complete intestinal obstruction, and in one case of cystic 
degeneration of the pancreas where large amounts of fat had been 
given, Fr. Miiller 15 could find no increase of fat in the stools. 

Absence of pancreatic juice, therefore, does not prevent the 
digestion of fat. On the other hand, the careful and thorough 
examinations of Fr. Miiller have shown that in these cases an 
insufficient splitting up of fat occurs. Whereas with a normal secre- 
tion of pancreatic juice or in icterus the greater portion (84 per 
cent) of fat in the feeces was split up, only 40 per cent (in round 
numbers) was split up in the absence of the jDancreatic juice. 
Should this fact be confirmed, it would constitute an important sign 
for diagnosing disturbances of the pancreatic secretion or occlu- 
sions of the pancreatic duct. This would be all the more important, 
since the other symptoms of these conditions — mellituria or mal- 
tosuria, multiple muscle fibres in the stool, and ptyalism — occur 
very rarely, and are only conclusive when all three are present. 
Conversely, since thorough splitting up of fat may result from 
bacterial action, it does not at all speak against occlusion of the 
pancreatic duct. Yery much interest also attaches itself to those 
acholic stools without icterus, which Bamberger 19 and Gerhardt 20 
described, and which have been particularly studied by Nothnagel 21 , 
von Jaksch,f Berggriin, and Katz 22 and Pel. 23 I have observed 
five cases of this kind. These acholic stools without icterus are 
characterized by containing a large percentage of fat or of fatty 
acids. Their reaction, therefore, is strongly acid. Urobilin has 
been repeatedly found in these colourless stools (in one of my own 
cases also). In the majority of cases the acholia was only tempo- 
rary. In one case under my observation the acholia continued for 
fourteen days ; unfortunately, further observation of the case was 

* Nothnagel, loc. cit., p. 20. f Von Jaksch, loc. cit., p. 292. 



EXAMINATION OF THE FAECES 105 

impossible. The large amount of fat present is very probably due 
to insufficient absorption. It is unnecessary to repeat that the rice- 
water stools of cholera nostras and asiatica are also acholic ; the 
cause is very probably an entire absence of intestinal secretion. 

The class of acholic stools under discussion has been observed 
under the most varied conditions in severe as well as in light cases. 
Thus JSothnagel observed acholia in leukaemia, in cancer of the 
stomach and intestines, in simple intestinal catarrh of children and 
adults, and most frequently of all in advanced cases of pulmonary 
tuberculosis. Yon Jaksch found acholic stools in intestinal tuber- 
culosis, chronic nephritis, anaemia, and scarlet fever. Berggrun 
and Katz observed and ascribed great importance to them in 
tubercular peritonitis in children. I myself have found acholic 
stools in cholelithiasis, where the icterus appeared a few days later. 
I have also seen it in a very feeble patient who suffered from 
stricture of the esophagus, and after the use of Carlsbad water and 
salts in a young lady suffering from chronic catarrh of the large (and 
small ?) intestines ; furthermore, in a patient with cancer of the pan- 
creas, and finally in a severe case of chronic constipation, where, on 
account of other clinical manifestations, the probable diagnosis of 
cancer of the large intestines had been made. 

At present our ideas as to the causes of this form of acholia have 
a purely theoretical basis. Nothnagel believes it is occasioned by 
a temporary cessation of biliary secretion. Yon Jaksch thinks the 
lack of colour is due to the non-formation of urobilin from bile pig- 
ments, or else that colourless products of decomposition of bilirubin, 
" leukourobilin " (von Nencki), are formed from the bile pigments. 
The absence of colour is very probably due to a large percentage of 
fat. We can readily imagine that, owing to certain influences (at 
present unknown), the fat, or rather the fatty soaps, are only par- 
tially or not at all absorbed from the small intestines. On the other 
hand, it can not be denied that the abnormal excretion of fat from 
the intestines may be caused by temporary or permanent disturb- 
ances of pancreatic or biliary secretions. Owing to the numerous 
possible causes of this form of acholia we can not at present assign 
any great diagnostic value to it. 

5. Determination oe Blood and Blood- colouring Matter in 

the FAECES 
With fresh blood, such as comes from the lower portion of the 
intestines, the macroscopical appearance of the faeces is so char- 



106 DISEASES OF THE INTESTINES 

acteristic that a microscopical control examination will seldom or 
never be required. Well preserved red and white blood-corpuscles 
may be demonstrated. Where the coloring matter of the blood has 
undergone changes the condition is quite different. The presence 
of blood-colouring matter may be demonstrated by microscopical, 
chemical, and spectroscopic analyses, which will now be collectively 
considered. 

(a) Blood, when present in the faeces, can seldom be demon- 
strated by microscopical examination. Even where the stools were 
still intensely red coloured, Nothnagel never could find erythrocytes 
in the fresh haemorrhages of typhoid fever. In these cases, how- 
ever, we can observe clumps of pigment which, according to von 
Jaksch,* are composed of haematoidin. 

(b) The Micro-chemical Demonstration (Hcemin Test). — A small 
particle of fasces that appears to contain blood-colouring matter is 
dried, then pulverized, and together with a minute particle of com- 
mon salt and one drop of glacial acetic acid brought upon a glass 
slide, and the whole mixed carefully for a few moments. A cover 
glass is then placed over the mixture and glacial acetic acid allowed 
to flow under the cover glass until the latter uniformly touches the 
slide. Thereupon the slide is held over a very small flame, care 
being taken that the glacial acetic acid does not reach the boiling 
point ; the heating may be repeated with the addition of fresh gla- 
cial acetic acid. When the specimen has cooled it is examined with 
the high power for haematin crystals.^ 

(c) Chemical Demonstration ( Weber's Test 24 ). — The fasces are 
extracted with glacial acetic acid and ether, and to a few cubic cen- 
timetres of this extract 10 drops of the tincture of guaiac and 30 
drops of oil of turpentine are added. In the presence of hsematin 
we can observe a pretty blue or violet colour, which, after the 
addition of water, can be extracted with chloroform. 

(d) Spectroscopic Demonstration. — A portion of the most 
darkly coloured part of the faeces is stirred with a little water, 
and, after the addition of a few drops of concentrated acetic acid, 
shaken with one fifth its volume of ether ; after a few moments the 
ether separates, and, if the faeces contain blood, is coloured a brown- 
ish red (due to the haematin). The ethereal haematin solution shows 
four spectroscopic absorption bands : one in the red, a second in 



* Von Jaksch, loc. cit., p. 232. 
f For unknown reasons the haemin test with faeces does not always succeed. 



EXAMINATION OF THE F^CES 107 

the yellow, a third between the yellow and the green, and a fourth 
between the green and the blue. That in the red is by far the 
darkest and most clearly denned. 

In most cases the demonstration of blood in the faeces is easy, 
but the determination of its origin is more difficult. In the first 
place, we must remember that blood may be physiologically intro- 
duced into the faeces through raw meat and some varieties of sausages. 
If these can be excluded a large amount of blood in the faeces is 
always a pathological condition. The causes are so numerous and 
varied that only through general and local examinations can the 
source be determined. The diseases of the intestines which fre- 
quently or occasionally cause haemorrhages include nlcers, neo- 
plasms, haemorrhoids, amyloid disease, intussusception, stenosis, 
ileus, anchylostomum, bothriocephalus, trichocephalus dispar, etc. 

6. Demonstration of Biliary Matter in the Faeces (Bile 
Pigments, Biliary Acids) 

As previously mentioned, the brown colour of normal stools is 
due to colouring substances formed through reduction of the bili- 
rubin or of the biliverdin of the bile. In adults, unaltered bile 
pigment (bilirubin, biliverdin) appears under pathological conditions 
only. Hence the demonstration of normal as well as of abnormal 
faecal colouring matter may have some diagnostic value. 

(a) Demonstration of Bile Pigments in Toto {Supjperf s Test) 

Thin fluid faeces (or artificially thinned fasces) are placed in a flask, an equal 
volume of milk of lime is added, and after repeated shaking the mixture is 
poured upon a small filter ; the precipitate which remains upon the filter con- 
sists of hydrobilirubin lime. This should be washed, and, while still moist, 
placed into a boiling flask with a very long neck, together with 20 cubic 
centimetres of alcohol to which sulphuric acid has been previously added to 
distinct acid reaction. The mixture is heated to boiling; in the presence of 
biliary colouring matter the fluid will acquire an emerald green or a bluish 
green colour. Positive reaction with Huppert's test simply indicates the pres- 
ence of bile pigment in the faeces, but tells nothing of its nature. 

(b) Test for Urobilin 

1. Mehu's test. The faeces are extracted with water and sulphuric acid 
in proportion to 2 grams to the litre and ammonium sulphate in substance 
are added to the watery extract. The resulting precipitate is separated by 
filtration, washed with a warm saturated solution of ammonium sulphate, 
dried over a water bath, and then extracted with hot ammoniated alcohol. 
Spectroscopic examination of this extract shows an absorption band between B 



108 DISEASES OF THE INTESTINES 

and F. The precipitate may be otherwise treated ; it may be dissolved with 
amrnoniated water and a 10-per-cent solution of chlorid of zinc added. In the 
presence of urobilin the fluid will show a very pretty fluorescence. 

2. A. Schmidt's test. 26 With a glass rod a fragment of faeces about the 
size of a bean is rubbed up in a beaker or porcelain dish with a concentrated 
watery sublimate solution. If urobilin be present the mixture immediately, 
or after a short time, acquires a rose colour; or if biliverdin be present, a green 
colour. According to the experiments of Dr. Hari in my laboratory, the 
reaction can be more quickly obtained by shaking the faeces with concentrated 
sublimate solution, filtering, and then adding chloroform to the filtrate. In 
the presence of urobilin a very pretty rose colour appears at the point of contact 
of the two fluids. 

3. Fleischer's method. 26 If a small quantity of faeces be placed in a 
small flask or a test tube and alcohol (to which hydrochloric, sulphuric, or 
acetic acid has previously been added) be poured over it and the whole allowed 
to stand a short time, it will be coloured yellowish or brownish, according to 
the proportion of urobilin contained. If the alcohol be then poured off and a 
few drops of caustic soda or ammonia solution added, and then chlorid of zinc 
solution, a green fluorescence with direct light and a rose-coloured or yellowish 
with transmitted light will be obtained. The degree of colour reaction is 
proportionate to the amount of urobilin present in the stools. If ammonia 
solution be added to a watery extract of the faeces, and, after filtration, chlorid 
of zinc solution, we will obtain a beautiful rose red or a dark red precipitate 
in the presence of urobilin; in the absence of urobilin, however, this precipi- 
tate will remain uncoloured. If this precipitate is brought upon a filter and 
washed with ammoniated alcohol, we will obtain a more or less marked green- 
ish fluorescence. 

(c) Determination of Unreduced Bile Pigments (Bilirubin, 
Biliverdin), Gmelirfs Test 

If nitroso-nitric acid be added to the faeces, the characteristic 
colours — red, violet, and green — will appear (in most cases only a 
green colour is seen). In like manner, after filtration of the faeces, 
we can obtain this test with the dried filter paper. In order to 
demonstrate bile pigment micro-chemically, a drop of the same acid 
is added to a small particle of faeces placed upon a glass slide. The 
reaction can be obtained either with the entire faeces or else with 
some of the ingredients — viz., mucus, epithelium, muscle fibres, etc. 

(d) Determination of Bile Acids 

A small quantity of the faeces is extracted with alcohol, the 
latter evaporated, and the residue dissolved in a very weak watery 
solution of soda. Upon addition of cane sugar and a few drops 
of sulphuric acid the characteristic red and purple colours of the 
bile acids appear (Pettenkoffer's test). Since the greater portion of 



EXAMINATION OF THE FAECES 109 

bile acids normally disappear by absorption, their presence in the 
dejections is always pathological. 

The diagnostic significance of the tests for biliary pigment in the 
faeces lies mainly in the fact that their presence proves a completely 
unobstructed flow of bile into the intestines, while their absence 
speaks for an obstruction to the flow of bile. According to Noth- 
nagel, 5 normal biliary pigment can be demonstrated only in thin, 
pasty, and fluid evacuations by Gmelin's test. If in such evacua- 
tions distinct reaction for biliary pigments is obtained, and the 
biliary pigment clings to the mucus or to the cylindrical epithelium, 
it points to catarrh of the small and of the large intestines. With a 
well-marked reaction we are justified in assuming that catarrh of 
the upper part of the small intestine is also present. 

7. Absence of Bile Pigment (Acholia) and Colourless Stools 

Whenever there is an obstruction to the flow of bile, colourless, 
clay-coloured stools result; also absolutely colourless stools may 
occur when there is no obstruction in the biliary passages. In 
obstruction to the flow of bile lack of colour is, on the one hand, 
due to an absence of bile pigments, and on the other to the pres- 
ence of abnormal amounts of fat and fatty acid in the stools. 

Bunge 27 has pointed out that the clay colour is due not to the absence of 
bile pigment but to the presence of large amounts of fat. If we extracted such 
acholic stools repeatedly with ether, they Avould assume a brownish colour, 
which, according to Bunge, results from the presence of hsematin and sulphate 
of iron. Guided by this, Fleischer 26 examined for and actually found hsema- 
tin in the three acholic stools; in a fourth he did not succeed. In all four 
stools urobilin was entirely absent. From these investigations Fleischer 
hopes for a better understanding of the causes and the nature of acholia in 
the faeces. 

Acholic stools occurring simultaneously with icterus point to an 
affection of the liver, the nature of which can only be determined 
by a closer examination. 

8. Determination of Aromatic Substances in the F^ces 
(Phenol, Indol, and Skatol) 

These aromatic bodies occur normally as well as pathologically. 

(a) Phenol. — To demonstrate the presence of phenol a portion 
of faeces must be distilled, and the distillate made alkaline with 
caustic potash and again distilled. The phenol then remains, and 
is purified by distillation with sulphuric acid. By the addition of 



HO DISEASES OF THE INTESTINES 

bromin water it can be demonstrated in the distillate as tribromo- 
phenol. Upon heating the distillate with Mill on' s reagent a red 
colour is obtained. A violet colour is obtained by the addition of 
chlorid of iron. 

(b) Indol and Skatol (Brieger). — To separate these bodies from 
phenol, the distillate of the faeces, after being made alkaline, is again 
distilled. Indol and skatol then pass over with the vapour of water. 
Indol forms colourless scales, and is soluble in hot water and in 
alcohol. Skatol also forms colourless scales, but is soluble with 
much more difficulty in water, and has a disagreeable penetrating 
odour. Unlike indol, it is not decomposed by caustics. With nitroso- 
nitric acid indol gives a distinct red colour ; when more concentrated 
a red precipitate may result. Pine shavings moistened with muri- 
atic acid are coloured red in a short time by an alcoholic solution 
of indol. Skatol gives neither the first nor the second test. At 
present these substances have no diagnostic significance, but a 
suitable method for their quantitative determination would very 
probably enable us to recognise different degrees of putrefaction 
within the intestines. 

9. Determination of Ferments in the F^ces 

For the purpose of demonstration, the ferments may be extracted 
with glycerin, and the glycerin extract used ; or, what is simpler, 
the faeces may be stirred with thymol or chloroform water, then fil- 
tered, and the tests made with the filtrate. For faeces, Leo ^ also 
recommends the use of blood fibrin, which has the property of 
absorbing ferments (discovered by Wittich). For this purpose faeces 
are mixed with chloroform water until they form a thin, pasty mass. 
In this mixture we suspend 2 to 5 grams of finely divided, pre- 
viously boiled blood fibrin, which is inclosed in a gauze bag tied 
with a thread. After twenty -four hours the gauze bag is taken out 
of the faeces, the fibrin washed a number of times with water, and 
then tested for the various ferments. To test for diastase, a small 
piece of fibrin is placed with some thin starch paste in an incubator, 
and after a while is tested with diluted Lugol's solution for the pres- 
ence of sugar or the disappearance of starch. 

To test for trypsin, a few pieces of fibrin in a 1-per-cent solution 
of soda are placed for a while in the incubator, and then tested for 
albumoses with caustic potash and very dilute sulphate of cop- 
per solution. If albumoses are present a pretty rose-red [or onion- 
red] colour is produced (biuret reaction). Yon Jaksch 29 and Leo 28 



EXAMINATION OF THE F^CES HI 

have demonstrated the presence of ferments in the dejections; 
diastase and invertin were found in children by von Jaksch, in adults 
by Leo. In normal and in many pathological conditions Leo was 
unable to find tryptic ferments, but he did, however, find them in 
many cases of diarrhoea. In a case of jejunal diarrhoea I found 
both amylolytic and tryptic ferments. 

10. Determination of Biliary Gravel and Gall Stones in 

the FAECES 

As is well known, biliary gravel and gall stones very often appear 
in the stools after attacks of cholelithiasis. They are very readily 
recognised in some cases, particularly where the stones are of large 
size, or are passed in large numbers. On the other hand, the macro- 
scopical recognition of biliary gravel is more difficult. Cholesterin 
is the principal ingredient of these concrements. In addition, they 
contain bile pigment combined with calcium (bilirubin- calcium), and 
bile acids combined with calcium, calcium soaps, and the carbonate 
of calcium. Appearance, colour, consistency, and size of the stones 
vary according to the proportion of the different ingredients. We 
differentiate especially between cholesterin stones which are hard 
and concentrically formed, and dark pigment stones which are not 
concentric, and are soft, small, and composed principally of bilirubin 
calcium. 

Chemical Examination. — This includes principally the demon- 
stration of cholesterin and biliary pigments. The concrements 
are pulverized in a mortar, and in order to remove all biliary 
components are boiled in water. After drying, the residue is 
extracted with a mixture of equal parts of alcohol and ether. This 
extract is then poured off, evaporated over a water bath, and under 
the microscope shows cholesterin in large rhombic plates with step- 
like notches. Chemically, cholesterin can be demonstrated by dis- 
solving a portion of the residue in chloroform and adding an equal 
amount of concentrated sulphuric acid. The chloroform solution 
then shows the following play of colours : blood-red, purple-red, 
and after longer exposure to the air, blue, green, and finally yellow. 
The micro-chemical demonstration of cholesterin is still easier. If 
to the crystalline mass on a glass slide concentrated sulphuric acid 
be added, the edges of the crystals will assume a carmin colour, 
which upon the addition of Lugol's solution changes to violet. 

To demonstrate gall-stone fragments we add dilute sulphuric 
acid to the residue left after boiling with water (vide above). The 



112 DISEASES OF THE INTESTINES 

formation of gas shows the presence of a carbonated salt. The 
mixture is heated, and after cooling is extracted with chloroform. 
With this chloroform extract Gmelin's test (see page 108) is to be 
made. 

For further tests for the various ingredients of bile concrements, 
the reader is referred to text-books on physiological chemistry. 

11. Pancreatic Stones 

Pancreatic calculi are very rarely passed in the stools. These 
stones have a rough surface, are friable, and can be broken off in 
facets. They are readily soluble in chloroform, and, according to 
Minich, 30 when heated evolve an aromatic odour. In one of Leicht- 
enstern's 31 cases chemical examination showed only carbonate and 
phosphate of calcium, but no bile pigment or cholesterin. The 
finding of pancreatic stones is of considerable diagnostic interest, 
for it proves conclusively the existence of a calculus. Unfortun- 
ately, owing to their great friability we rarely find these stones. 
We would, however, recommend that the dejections be examined in 
cases of cholelithiasis without icterus, and particularly in cases of the 
so-called " neuralgia of the liver." 

12. Recal Stones (Coproliths) and Intestinal Stones 
(Enteroliths) 
Faecal stones or coproliths are formed from inspissated masses 
of faeces and may acquire a size and firmness sufficient to cause 
obstruction of the intestine. They develop in portions of the 
large intestine in which the outward propulsion of the contents is 
attended with difficulty — i. e., at the flexures and in the ampulla 
of the rectum. As is well known, the vermiform 'appendix is a 
special point of predilection for faecal stones (see chapter on Ap- 
pendicitis, in Part II). Peal enteroliths, on the other hand, are 
much smaller bodies, and only very seldom give rise to intestinal 
obstruction. According to Leichtenstern's investigations, we may dis- 
tinguish three forms of enteroliths, viz. : 1. Heavy, brown, con- 
centric concrements of stony consistency, composed mainly of phos- 
phates of calcium and magnesium, and containing some foreign body 
in their interior (e. g., pieces of bone, hairs, fruit seeds, ascarides, 
ova, etc.). 2. Stones light in weight, composed of a fungoid mass 
of undigested vegetable matter. They occur in poor people who 
eat much oatmeal (oat stones). 3. Stones resulting from long-con- 
tinued use of certain drugs (calcium carbonate, magnesia, sodium 



EXAMINATION OF THE F^CES 113 

bicarbonate, salol, alcoholic solutions of shellac, etc.). This variety 
may acquire a considerable size. For the chemical character of 
these stones the reader is referred to text-books on physiological 
and pathological chemistry. 

13. Determination of Inorganic Substances in the F^ces 

The faeces contain inorganic salts in amounts varying from 1 to 
8 per cent. These consist principally of earthy phosphates ; in 
addition, there are also small amounts of iron, silicic acid, sodium 
chlorid, sodium sulphate, etc. Of the soluble inorganic substances, 
sodium chlorid, at all events, possesses practical interest. To dem- 
onstrate its presence, the faeces should be mixed with water and 
allowed to stand a few hours and then filtered. The filtrate is 
acidulated with nitric acid, and if a cloudiness results should be again 
filtered. Thereupon a few drops of silver nitrate are added and a 
white precipitate forms (silver chlorid). For the quantitative de- 
termination of sodium chlorid, see the text-book of Hoppe-Seyler 
and Thierfelder. 12 

3. The Microscopical Examination 

Technic. — Thin, pasty, or fluid feces may be examined with- 
out special preparation.* For the better examination of the insol- 
uble portions, fluid faeces may be poured into a conically shaped 
glass, or, still better, centrifuged (Herz 32 ). In the case of firm 
stools, a small particle is taken and mixed with physiological salt 
solution. For very exact examinations it is best to take only par- 
ticles the size of a pin's head. The ingredients to be microscop- 
ically examined for are : 

1. Food remnants. 

2. Elements derived from the intestines. 

3. Micro-organisms. 

4. Crystalline bodies. 

1. The following food remnants are met with normally or 
pathologically : 

{a) Muscle Fibres. — These occur not only in excessive meat 
diet, but also in mixed diet. They may have well-preserved striae, 
or more frequently they are seen as prismatic bodies with indis- 
tinct or obliterated striae. J^othnagel, 21 however, states that with 

* The addition of 1- or 2-per-cent formalin solution effectively deodorizes fasces. 



114 DISEASES OF THE INTESTINES 

the very high power even in these cases he could observe trans- 
verse striations. Occasionally the muscle fragments can be readily 
recognised macroscopically, or even singled out as brown spots. 
Under most diverse conditions muscle fibres are found in increased 




I 



Fig. 13. — Different Vegetable Substances found in Faeces. 
(Original observation.) 

numbers ; in diabetics, who, as is well known, eat very much meat, 
in persons suffering from fever, particularly when there is increased 
peristalsis (e. g., typhoid) — in fact, in any condition in which there 
is a marked increase in the peristalsis of the small and large 
intestines. In general the appearance even of large numbers of 
muscle fibres in the fasces has no diagnostic significance. Only 
their constant increase has any definite value. In the following 
sentence ISTothnagel very carefully formulates this law : " Only 
where, in the absence of fever and in the presence of definite symp- 
toms of catarrh (mucus, etc.), we find an abnormally large amount 
of muscle fibre in the fasces, is it permissible to conclude that 
catarrh of the small intestines is very probably also present." 

I fully agree with this statement, and would complete it by 
remarking that the macroscopical rather than the microscopical 
examination is decisive. Should we constantly observe undigested 
masses of meat, together with large quantities of mucus in the 
fasces of patients under moderate meat diet and with well-preserved 
teeth, the diagnosis, catarrh of the small intestines, is almost cer- 
tain. The reverse of this statement is not true. Although it is true 
that in pancreatic disease large quantities of muscle fibres fre- 
quently appear in the stools, we may to-day regard as entirely 



EXAMINATION OF THE F^CES 115 

disproved the opinion defended by Friedreich ^ a number of 
years ago, viz., that abundance of muscle fibres in the faeces indi- 
cates pancreatic disease. 

(b) Starch. — Normally, and also in disease, starch is so com- 
pletely digested that the appearance in the faeces of numerous 
vegetable remnants, and especially of well-preserved, concentrically 
arranged starch granules, is of pathological significance. According 
to my investigations, the following differences have been noted : 
Upon the addition of iodin to the faeces, in many cases a blue col- 
our is obtained, while in others again a more violet or even a rose 
colour appears. "Without doubt the first colour (blue) is indicative 
of a more serious interference with starch digestion. Besides iso- 
lated starch granules we may also find vegetable remnants that con- 
tain starch, and which appear either as threads, particularly spirals, 
or as large, square, meshlike bodies (Fig. 13) frequently contain- 
ing chlorophyl, or, finally, as large striated globules similar to those 




Fig. 14. — Fatty Stools, showing a Large Amount of Fatty Acid Crystals. 
(Original observation.) 

that I have described and pictured in the stomach contents. 34 It 
is very remarkable that starches, unlike muscle fibres and fats, are 
never stained by bile pigment. 

(c) Fats. — Fat appears either in the form of drops or of col- 
ourless, occasionally yellowish, clumps. . Fat crystals consist either 



116 



DISEASES OF THE INTESTINES 



of fatty acids or of fatty soaps. Fatty acids (Fig. 14) are short, 
delicate, partly curved needles, whereas the soaps (Fig. 15) are 
formed as long needles arranged in clusters or fan-shaped. When 
heated over a flame the fatty acids dissolve, but the soaps remain 
unchanged. Fatty acids are soluble in ether ; soaps are only soluble 
in ether after previous splitting up by acids. These characteristics 
enable us in every case to determine the nature of fatty crystals. 

Rieder 35 has recently recommended a new colour reagent for 
fats, suitable for clinical purposes. It is known as Sudan III, and 




Fig. 15.— Fatty Soaps in Faeces. 

Taken from a case of chronic catarrh of the small and large intestines. 

(Original observation.) 

is a diazo-colouring substance with the formula C22H 10 N 4 O. It is 
employed in concentrated alcoholic solution, filtered just before 
using. In fatty stools the fat drops are stained from an orange to a 
blood-red colour, while fatty acid needles and calcium and mag- 
nesium soaps remain uncoloured. 

(d) Coagulated Albumen. — In diarrhceal stools, especially after 
excessive dieting with milk, we may, according to Nothnagel, see 
lumps of casein varying in size from half a lentil to a pea, and fre- 
quently stained externally with bile, while internally they are as 



EXAMINATION OF THE F^CES 117 

white as milk. In like manner, after eggs have been partaken of 
in large quantities, small fragments of them may be observed in 
the dejections. 

2. The substances derived from the intestines themselves in- 
clude red and white blood cells (pus cells), epithelium, mucus, and 
tumour fragments. 

(a) Blood and Pus Cells. — Eegarding the red blood cells I 
would refer the reader to what has been already said on page 106. 
Although exceedingly rare, white blood cells do appear normally in 
the stools ; they are more frequently met with in pathological stools, 
and are most frequent in catarrhs. Their appearance in great num- 
bers indicates ulcerative processes within the intestinal canal. The 
most important facts concerning this subject have already been 
considered on pages 64 and 95. 

(ft) Epithelium. — This is usually of the cylindrical and but sel- 
dom of the pavement variety. Yery rarely in diseases of the rec- 
tum (rectal cancer, proctitis) we find pavement epithelium. It is, 
however, of no symptomatic importance. Cylindrical epithelium 
is more important. It may be unaltered, or more frequently can 
assume the greatest alterations in form. The cells may or may 
not retain their nucleus (degenerated epithelium). Microscopically 
we may observe all possible changes from the normal appear- 
ance of epithelium to that of degeneration. Minute fat globules 
are also frequently seen in the epithelial cells. A. Schmidt 25 has 
indisputably proved that mucous shreds, too, may contain a consider- 
able amount of fat. Fig. 16 explains all this much better than any 
description could. Epithelial cells are best studied in fresh mucus, 
such as is obtained in test lavage. In a few instances I have also 
noticed goblet cells, occasionally with intact basement membrane. 
Large quantities of cylindrical epithelium with mucus usually indi- 
cates a desquamative catarrh, whose location must be determined by 
other symptoms and signs, some of which have already been men- 
tioned. In addition to these formed structures in normal and 
pathological faeces, we may also find large and small bodies that can 
be differentiated with difficulty and that are extremely resistant to 
reagents. This detritus is derived in part from the food as well as 
from the secretions and excretions of the intestines. 

(c) Mucin. — Mucin is mainly characterized by its striated base- 
ment substance, in which epithelial cells are embedded in varying 
numbers. In some cases the cells predominate to such an extent 
that the striated structure of the mucin becomes indistinct or is 
9 



118 DISEASES OF THE INTESTINES 

apparently absent. Still, in some portions of the specimen it will 
always be recognisable by its layerlike appearance* In doubtful 
cases its presence can be determined by the Hoyer-Ehrlich thionin 
colour test. Mucus is here coloured a reddish violet, and all other 
proteid bodies blue. According to Sven Akerlund, 36 eosin, safranin, 
methylene blue, and hsematoxylin also colour mucus very satis- 
factorily, but not so as to admit of any differentiation from other 
proteid bodies. "We have already discussed the significance of 
mucus in the faeces (page 95). We would, however, repeat that 




Fig. 16. — Normal and Degenerated Epithelial Cells from the Mucous Shreds of a 
Case of Membranous Enteritis. (Original observation.) 

pure, macroscopically visible mucus, such as is obtained in intes- 
tinal lavage, can only come from the large intestines. 

3. Micro-organisms. — The faeces contain a greater number of 
micro-organisms than any other excretion of the body. They cer- 
tainly play a great physiological and pathological role. Notwith- 
standing that the important investigations of ISencki, Macfadyen, 
and Sieber, 37 as well as of Thierfelder and Nuttal, 38 have shown that 
normal digestion is possible without the aid of bacteria, we can not 
deny them some significance. Their activity need not be limited to 
action upon digestive matter, but may also include reciprocal action 
on other pathogenic organisms. As usual in bacteriology, we here 
distinguish moulds, yeasts, and schizomycetes (bacteria). 



EXAMINATION OP THE F^CES 119 

(a) I have but once observed mould fungi in faeces (aspergillus 
filaments). The oidium albicans has occasionally been observed in 
the stools of children. 

(b) Saccharomyces. — Of these the yeast is the most important. 
It is a frequent constituent of normal and quite commonly of patho- 
logical stools. It appears either as single cells or in pearly chains. 
It frequently shows budding. Usually the cells are oval, more 
rarely they are round. We find them both in firm and in diarrhceal 
evacuations, although they are more common in the latter variety. 
The reaction of the faeces seems to have no influence upon their 
growth, for I have met with them in alkaline as well as in acid 
stools. With Lugol's solution they are stained a yellowish or 
mahogany brown. Yon Jaksch quite correctly calls attention to the 
occurrence in the faeces of bodies very similar to yeast cells, but I 
have noticed that they are for the most part smaller than yeast 
cells and have no double contour and do not bud. Furthermore, 
they differ from yeast cells in giving the same reaction as starch 
with Lugol's solution. They should very probably be classed with 
the clostridien (page 121). 

(c) /Sarcina (Gooclsir) (Fig. IT). — Strange to say, the occurrence 
of genuine, fully developed sarcinae in the faeces appears to be but 
very little known. They are not infrequently found in the stools 
of patients suffering from gastrectasia. Several times I have thus 
had my attention directed to an existing gastrectasia with masked 
symptoms. In one case, however, in which I found them in the 
evacuations there was no gastrectasia present. Usually the evacua- 
tions in which sarcinae appeared in very large numbers were of a 
diarrhceal nature, and the question therefore suggests itself whether 
or not the migration of sarcinae en masse into the intestinal canal 
can not give rise to fermentative processes in the latter. As already 
remarked, sarcina intestini in no wise differs from the sarcina ventri- 
culi. As in the latter we also find, in addition to well-formed, brown- 
ish yellow or lighter coloured bundles, those small coccous forms 
whose constriction is indicated only by a loose cementing mem- 
brane. Like the sarcina ventriculi, the sarcina intestini also shows 
a distinct cellulose reaction with iodin and chlorid of zinc solution. 

(d) Bacteria. — Undoubtedly bacteria form the greater percent- 
age of the micro-organisms occurring in the intestines, or rather in 
the faeces. They consist both of micrococci and bacilli. Accord- 
ing to von Jaksch, thin stools as a rule contain more bacilli and firm 
ones more micrococci. Some of these organisms are motile. 



120 



DISEASES OF THE INTESTINES 



1. By far the most numerous are those bacilli first described by 
Escherich as belonging to the group of bacterium coli. They are 
quite thick, short rods, in part motile and partly immobile ; in 
appearance and growth upon most nutritive media they very much 
resemble the typhoid bacilli. Unlike the typhoid bacilli, they do 
not curdle sterile milk and develop gases (C0 2 and H) in nutritive 
media containing sugar. Their size varies widely, ranging between 
0.5 and S/jl. 

Careful study of this variety of bacteria has shown that they 
are really made up of several groups resembling one another, and 




Fig. 17. — Faeces from a Case of Chronic Enteritis, showing S arcing. 
A, starch granule ; K, fractured triple phosphate crystal ; J/, muscle fibres ; E, epithelial 
cells ; i?, goblet cells; P, vegetable cells and fibres. (Original observation.) 

which, as it appears, can merge from one into the other, thus per- 
mitting the formation of pathogenic organisms from innocent sap- 
rophytes. Thus a large number of diseases have already been 
observed in which it is suspected that the bacterium coli plays 
an important role — e. g., cholecystitis and cholangitis, appendicitis, 
acute dysentery, peritonitis, etc. 

The addition of one per cent of iodid of potash to the culture 
media, as advocated several years ago by Eisner, 39 but more particu- 
larly the well-known Widal's test, 40 enables us to distinguish typhoid 
bacilli from the colon and other bacilli. 



EXAMINATION OF THE FAECES 121 

2. Bacillus Subtilis (Hay Bacillus). — This bacillus, first observed 
in the faeces by Nothnagel, is very often met with under normal 
as well as pathological conditions. It forms either long, motile fil- 
aments with spores, or isolated bacilli with spores, or, finally, groups 
of spores. It is readily recognised by its thick contours as well as 
by its strongly refractive spores. It stains yellow or yellowish 
brown with Lugol's solution. It has no special significance. 

3. Bacterium Lactis dErogenes. — These are thick, short rods, 
1-2//, in length and 0.5/a in width. They are immotile. They are 
characterized by their property of causing milk to curdle and to 
ferment with the formation of gas within sixty hours. On potatoes, 
also, the bacterium lactis forms gases. Besides milk sugar, they 
also cause cane sugar to ferment. It is possible that owing to its 
active gas-forming properties the bacterium lactis plays an impor- 
tant part in the etiology of meteorism ; but of this we know noth- 
ing certain. 

4. Bacillus Putrificus Coli (Bienstock). — These are slender 
rods about 3/jl in length, which frequently form long threads. The 
spores are marginal, and develop at one or both ends ; if at one end 
only, they give the bacillus a drumstick appearance. The bacil- 
lus, especially in the presence of air, causes a rapid decomposition 
of albumin with the formation of ammonia, amin bases, amido- 
fatty acids, tyrosin, phenol, indol, etc. I have very often observed 
the bacillus in stomach contents as well as in faeces, but, unlike 
Bienstock, would not consider it as a regular parasite of the faeces. 

5. Organisms that Stain Blue with Iodin. — Nothnagel has ob- 
served a number of micro-organisms which stain blue with iodin, 
and he regards one variety as identical with the Clostridium buty- 
ricum of Prazmowski. The bacillus butyricus (Fig. 18) forms rods 
from 3/L6 to 10/x in length and 1/m in width, and frequently occurs in 
chains. It is sometimes said to form long filaments which are quies- 
cent sometimes, at other times mobile. Usually the bacillus butyricus 
is lemon- or lozenge-shaped and forms large clusters. It gives a very 
pronounced iodin reaction. The bacillus is anaerobic. It causes 
an active fermentation of starches, dextrin, sugar, lactates, and cel- 
lulose. The bacillus butyricus is very probably the chief agent in 
the formation of butyric acid and of gases in the intestines. Ac- 
cording to von Jaksch, with whom I fully agree, the bacillus buty- 
ricus is found in especially large numbers in pathological conditions 
of the intestines. In almost every normal stool we find it in 
smaller numbers. It does not have any pathological significance. 



122 DISEASES OF THE INTESTINES 

The pathogenic organisms occurring in the fseces include the 
cholera, typhoid, and tubercle bacilli. Since a work like the pres- 
ent one can not include a discussion of the acute infectious diseases, 
the tubercle bacillus is the only one we shall speak about. 




Fig. 18. — Bacillus buttbicxjs {Clostridium lutyricum) stained with Iodin. 
(Original observation.) 

Assuming its morphology to be well known, we would simply 
say regarding its demonstration, that the technic differs in no 
manner from that of sputum examinations, and it is entirely super- 
fluous to enter here into the details of that procedure. As to the 
diagnostic significance of tubercle bacilli in the faeces, it may be 
summed up as follows : It is conclusive of a tubercular process in 
the intestines when we know positively that the material examined 
comes directly from the intestines — as, for example, in tubercular 
rectal ulceration. Otherwise the question of intestinal tuberculo- 
sis must remain in doubt. 

The diagnosis, intestinal tuberculosis, can, however, be made 
with certainty where there is an entire absence of sputum, and 
tubercle bacilli constantly appear in stools that are of a thin, bloody, 
or purulent character. 

Cocci are also found in the fseces, though not as frequently as 
bacilli. Since they are of much less practical importance, we shall 



EXAMINATION OF THE F.ECES 



123 



refrain from their discussion, referring the reader to Mannaberg's 
able description in Nothnagel's work on Intestinal Diseases. 

6. Crystalline Bodies. — These may be organic or inorganic, and 
are seen very often in the faeces. With the exception of the biliary 
concrements previously mentioned (see page 111), the diagnostic 
importance of crystalline bodies is very slight. Since they may 
be mistaken for other similar substances it is necessary to be able 
to recognise them. The following are the principal crystalline 
bodies which come into consideration : 

(a) Hcematoidin Crystals. — Yon Jaksch has observed these in 
long-continued catarrhs following stasis, and also in many cases in 
which intestinal haemorrhages had but a short time previously 
occurred. Usually haematoidin shows an indistinct crystalline struc- 
ture ; the crystals are in part free and in part embedded in a lustre- 
less, mucoid mass. I have never been able to find the bodies men- 
tioned by von Jaksch. 10 

(b) Cholesterin. — It is extremely rare to find cholesterin pres- 
ent as fully formed rhombic plates. This applies as well to normal 
as to pathological stools. Only once after the administration of 
nutritive enemata have I seen them in large quantities. ]^othnagel 
has seen them after nutritive rectal enemata of peptone, wine, and 
eggs. This author quite correctly calls attention to the very decep- 
tive similarity between fragments of triple phosphates and choles- 
terin scales. Indeed, the resemblance 
is so close that I have frequently 
only learned my error through ob- 
taining a negative cholesterin reac- 
tion. Cholesterin also undoubtedly 
appears in normal faeces in an amor- 
phous form; neither form has any 
diagnostic significance. 

(c) Charcot- Ley den Crystals (Fig. 
19). — These are by no means ex- 
tremely rare. They are identical 
with the crystals found in asthmatic 
sputum. In the same specimen they 
may vary very much in size. Some- 
times they can be distinctly seen only with the highest power lenses. 
They are insoluble in alcohol, ether, and chloroform, but very 
soluble in hydrochloric acid and alkaline solutions. This permits 
of their ready distinction from fatty acid crystals. They stain with 




Fig. 19.— Charcot-Leyden Crystals 
from Faeces. (Original observation.) 



124 DISEASES OF THE INTESTINES 

carmin, and can then be preserved for a long time, ^othnagel 5 
has observed their appearance under most varied conditions — viz., 
reconvalescence from typhoid, typhoid at the height of the disease, 
phthisis, in dysenteric disturbances of the large intestines, in a 
rachitic child with firm stools, and in a child with profuse evacua- 
tions resulting from chronic catarrh of the large and small intes- 
tines. Perroncito 41 and Baumler 42 first discovered the crystals in 
persons suffering from anchylostomal disease. This was the status 
of the question when Leichtenstern, in 1892, called attention to the 
coincident occurrence of these crystals with various intestinal para- 
sites (ascaris, anchylostomum, trichocephalus, oxyuris, taenia, etc.), 
and stated that entozoa, whatever be their nature, were the most 
frequent cause of the formation of Charcot-Leyden crystals in the 
intestines, and of their subsequent appearance in the fseces. From 
this it follows, therefore, that the crystals possess great diagnostic 
value ; if found in the fseces we may with the greatest probability, 
perhaps certainty, conclude that the patient in question is suffering 
from intestinal entozoa of some kind (Leichtenstern 44 ). 

Conversely their absence does not in any manner exclude ento- 
zoa. Leichtenstern based his views on the significance of the 
coincidence of the Charcot-Leyden crystals and entozoa, especially 
upon the fact that at autopsies he was always able to find them 
in those portions of the intestines in which, from experience, we 
know the parasites in question are usually found. In anchylos- 
tomiasis, in particular, these crystals are found with such con- 
stancy that he states that they are distinctly pathognomonic of that 
disease. Strange to say, little attention has been paid to this 
important discovery of so great a clinician as Leichtenstern, who 
has made excellent researches, especially regarding entozoa. The 
question has only been discussed in Roesen's dissertation ^, where, 
after an examination of seventeen cases of entozoa, an entirely 
negative result was reached. My own experience in the matter 
is too slight to demand recognition, but from the study of one case 
I have gained the impression that the value ascribed to them by 
Leichtenstern is correct. 

The case in question was that of a gentleman thirty-six years old, who suf- 
fered from chronic catarrh of the large intestines, and whose stools I used fre- 
quently to examine very carefully. During one examination I found, in the 
mucous portions of the stool, Charcot-Leyden crystals both of moderate and 
very large size. Although not attaching much importance to my observation, 
I took note of it, and upon repeated examinations the same condition was 
observed. After three or four w r eeks the patient brought me taenia proglottids, 



EXAMINATION OF THE FAECES 125 

whereupon a taenia mediocanellata was readily removed. In spite of most 
careful examination tapeworm eggs could never be found. 

This case needs no farther comment.* Leichtenstern's discovery 
is certainly worthy of greater attention than it has heretofore 
received. 

(d) Fatty Acids and Fatty Soap Crystals. — We have already 
touched upon the most important points in this connection (pages 
115 and 116). We here wish to add that the opinion expressed 




Fig. 20. — Yellow Calcium Salts from Faeces. 
In some the concentric arrangement of the layers is well seen. (Original observation.) 

by Gerhardt ^ a long time ago, that the crystalline bodies occurring 
in acholic stools might be tyrosin crystals, has been wholly refuted 
by the investigations of Oesterlein * Stadelmann 46 , Fr. Muller 15 , 
and von Jaksch 10 . 

(e) Phosphate of Calcium. — This occurs in the faeces as neutral 
phosphate of calcium and as yellow calcium salts. The former con- 
sists of small or large wedge-shaped bodies, arranged for the most 

* It struck me as strange that when entozoa eggs were present the crystals were 
frequently missing. Besides numerous cases of taenia, ascaris, and oxyuris under 
my own observation, I would also mention a case of trichocephalus dispar in which 
Charcot-Leyden crystals were vainly looked for repeatedly by both my assistants 
and myself. 



126 DISEASES OF THE INTESTINES 

part in groups with converging apices. This variety does not 
absorb bile. Yellow calcium salts (Fig. 20) (whose acid has not yet 
been determined) usually assume irregular, oval, or circular forms. 
They are frequently fissured, and in some cases are arranged in con- 
centric layers. The yellow colour comes from imbibition of bile. 
Neither form has any diagnostic significance. 

(/) Oxalate of Calcium. — This occurs in the well-known en- 
velope form. The crystals may be small or large. They are 
found especially in patients under largely vegetable diet. These 
crystalline bodies are met with in normal as well as in pathological 
stools. 

(g) Ammonium-magnesium Phosphates (Triple Phosphates). — 
These crystals are one of the most frequent crystalline elements of 

normal or pathological stools, espe- 
cially fluid stools. They appear 
J* *& most frequently in the well-known 

/"**"^/ coflin - cover shape, more rarely 

jp l__^j \^ feather- shaped. The coffin-cover 

jj " +JJL [ fragments frequently show tears 

i$Q * * .-J* W* and fractures (Fig. 17), and thus 

j 4(t yoi ma J occasionally resemble choles- 

f> fa (Jy terin crystals. The solubility of the 

** w " +m triple-phosphate crystals in acetic 

\\~ ■■» acid enables us to avoid error in 

^ * diagnosis. They have no diagnostic 

Fig. 21.— Bismuth Cbtstals from vame. 

Fjsces. (Origiual observation.) (A) Sulphate of Calcium. — The 

appearance of sulphate of calcium 
in the faeces is said to be extremely rare. I have never seen it in 
the dejections themselves, but once by the addition of sulphuric 
acid to faeces obtained some very pretty sulphate of calcium 
needles in the sediment, which consisted principally of bilirubin- 
calcium. 

(i) Bismuth Crystals. — Yery soon after administration of bis- 
muth, irregular shaped, rhombic, dark brown or black crystals are 
excreted (Fig. 21). Until recently these have been regarded as 
sulphate of bismuth, but, as previously mentioned, Quincke showed 
that they consist of bismuth oxydyl. 



EXAMINATION OF THE FAECES 127 



LITERATURE 

1. Fleischer. Lehrbuch d. inneren Medicin, Bd. ii, 2te Halfte, S. 1139. 

2. Quincke. Mtinchener med. Wochenschr., 1896, No. 36. 

3. Quincke u. Roos. Berl. klin. Wochenschr., 1893, No. 45. 

4. Boas. Deutsch. med. Wochenschr., 1896, No. 14. 

5. Nothnagel. Beitrage zur Physiologie u. Pathologie cles Darms, Berlin, 

1884. 

6. Ad. Schmidt. Zeitschr. f. klin. Medicin, 1897, Bd. xxxii, Heft 3 u. 4. 

7. Pariser. Deutsch. med. Wochenschr., 1893, No. 41. 

8. J. Kaufmann. New Yorker med. Wochenschr., November, 1895. 

9. Blauberg. Experimentelle u. kritische Studien liber Sauglings-faces, u. s. w., 

etc., Berlin, 1897, S. 37, u. f. 

10. von Jaksch. Klinische Diagnostik, 4te Aufl., S. 277. 

11. von Jaksch. Ibid., S. 278. 

12. Hoppe-Seyler — Thierfelder. Handbuch d. physiolog. u. patholog.-chem- 

ischen Analyse, 5te Aufl , S. 479. 

13. Biedert. Jahrbuch fur Kinderheilk., 1878, 1879, u. 1881. 

14. Demme. 12ter Jahresbericht des Jenner'schen Kinderspitals in Bern, 

1874. 

15. Fr. Muller. Zeitschr. f. klin. Med., 1887, Bd. xii, S. 45-113. (Here will 

also be found a resume of previous literature.) 

16. Abelmann. Inaug.-Dissert., Dorpat, 1890. 

17. Saudmeyer. Zeitschr. f. Biologic 1895, Bd. xxxi, S. 12. 

18. Teichmann. Inaug.-Dissert., Breslau, 1891. 

19. Bamberger. Die Krankheiten d. Chylopoetischen Apparatus. Virchow's 

Handbuch, Bd. vi. 

20. Gerhardt. Zeitschr. f. klin. Med., Bd. vi, 1883. 

21. Nothnagel, loc. cit., S. 127, and Die Erkrankungen d. Darmes u. Peri- 

toneum, S. 17. 

22. Berggrtin u. Katz. Wiener klin. Wochenschr., 1891, S. 158. 

23. Pel. Centralbl. f. klin. Med., 1887, S. 297. 

24. H. Weber. Berl. klin. Wochenschr., 1893, No. 19. 

25. A. Schmidt. Yerhandlungen d. Congresses f. innere Medicin, 1895. 

26. Fleischer. Lehrbuch der inneren Medicin. 2ter Th., 2te Halfte, 1896, S. 

1160. 

27. Bunge. Lehrbuch d. physiolog. u. patholog. Chemie, Leipzig, 1887, 

S. 192. 

28. Leo. Diagnostik d. Krankheiten d. Bauchorgane, 1895, 2te Aufl., S. 348. 

29. von Jaksch. Zeitschr. f. physiol. Chemie, Bd. xii, S. 116, u. Klinische 

Diagnostik, 4te Aufl., S. 286. 

30. Minich. Berl. klin. Wochenschr., 1894, No. 8. 

31. Leichtenstern. Penzoldt-Stintzing Handbuch d. speciellen Therapie, Bd. 

iv, Abth. vi, 15, S. 206. 

32. Herz. Centralbl. f. klin. Medicin, 1892, p. 883. 

33. Friedreich. Krankheiten des Pankreas in von Ziemssen's Handbuch d. 

spec. Pathol, u. Therapie, Bd. viii. 



128 DISEASES OF THE INTESTINES 

34. Boas. Diagnostik u. Therapie d. Magenkrankheiten, Bd. i, 4te Aufl., S. 

231, Fig. 26. 

35. Rieder. Deutsch. Arch. f. klin. Med., 1898, Bd. lix, H. 3 u. 4, S. 444. 

36. Sven Akerlund. Arch. f. Verdauungskrankheiten, Bd. i, S. 396 u. f. 

37. Nencki, Macfadyen u. Sieber. Arch. f. experiment. Pathologie u. Pharma- 

cologie, Bd. xxviii, S. 311-350. 

38. Thierfelder u. Nuttal. Zeitschr. f. physiol. Chemie, Bd. xxi, 1895, S. 

109-129, and Bd. xxii, 1896, S. 62-73. 

39. Eisner. Zeitschr. f. Hygiene, Bd. xxi, S. 25, 1895. 

40. Widal. Semaine medicale, 1896, No. 33. 

41. Perroncito. Re vista della Accademia di Torino, II Morgagni, 1881. Cen- 

tralbl. f. d. medicin. Wissenschaften, 1881. 

42. Baumler. Correspondenzbl. f. Schweizer Aerzte, liter Jahrg., 1881, No. 1. 

43. Leichtenstern. Deutsch. med. Wochenschr. , 1892, No. 25. 

44. L. Roesen. Inaug. -Dissert., Bonn, Crefeld, 1893. 

45. Oesterlein. Mittheilungen a. d. med. Klinik in Wiirzburg, Bd. i, 1885. 

46. Stadelmann. Deutsch. Arch. f. klin. Med., Bd. xl, S. 372, 1887. 



CHAPTEK VI 

THE DIAGNOSTIC VALUE OF THE EXAMINATION OF THE 
STOMACH CONTENTS IN INTESTINAL DISEASES 

In the diagnosis of difficult intestinal diseases an analysis of the 
stomach contents is sometimes very important, or may even be 
decisive. In the first place, it enables us to exclude diseases of 
the stomach itself. Thus, for example, if we find a poorly defined 
tumour, from whose location alone it would be impossible to say 
whether it belongs to the stomach, the intestines, or the omentum, 
and where, in addition, there are general evidences of a serious dis- 
eased condition, the finding of normal stomach contents would in all 
probability speak against gastric cancer. On the other hand, abnor- 
mal stomach contents does not signify absence of the disease of the 
intestines. As an illustration of this by no means " rare complica- 
tion," I may cite a very interesting case reported by Pulawski 1 , in 
which the clinical picture was that of a dilatation of the stomach and 
a tumour in the epigastrium, while the autopsy revealed a primary 
cancer of the caecum. The gastric tumour felt was occasioned by 
an aggregation of carcinomatous lymphatic glands which com- 
pressed the pylorus and caused a stenosis. The mucous membrane 
of the stomach was entirely normal. The reverse of this case is 
more frequently met with — i. e., a gastric tumour becomes displaced 
and simulates an intestinal neoplasm. Here, at times, examination 
of the gastric contents may clear up the diagnosis. What has 
always struck me as remarkable, and what also speaks for the diag- 
nostic value of these examinations, is the fact that in cancer of the 
intestines, excepting where the tumour is very near to the pylorus, 
the gastric secretions may still be normal even in the most extreme 
stage of cachexia. Examination of the stomach contents may also 
give conclusive evidence for the diagnosis of a stenosis below the 
duodenum. It can, however, only indicate the existence of a ste- 
nosis, the nature of which must be determined by other means. In 
these cases the stomach contents are always bile tinged, especially in 

129 



130 DISEASES OF THE INTESTINES 

the fasting state. I was the first to show that, besides bile, pan- 
creatic, and very probably, too, intestinal secretion, pass into the 
stomach. Hence we may sometimes observe the paradox, duodenal 
digestion occurring within the stomach. This can happen only where 
the gastric secretion, as is frequently the case, becomes weakened or 
entirely suppressed through the action of the intestinal fluids, espe- 
cially of the bile. As has already been shown on page 44, when the 
gastric juice remains sufficiently acid no variations from the nor- 
mal occur. We may even find an alternating reaction of the gastric 
contents, according as intestinal or gastric factors predominate. 
Cohn, Kiegel, Hochhaus, Schule, Herz, and I, have published 
examples of this last-named condition. 

The presence of pancreatic juice in the stomach can be readily 
demonstrated by its tryptic action. Its demonstration, I believe, 
might be of importance in determining the etiology of a stenosis, 
for with a palpable tumour in the region of the ascending portion 
of the duodenum, the occurrence of pancreatic ferments in the 
stomach contents would speak for, and the absence of such ferments 
against, the existence of a pancreatic tumour ; still, I can not sup- 
port this statement by actual cases.* 

Besides the deeply situated duodenal stenoses, the much rarer 
ones of the jejunum can, I think, also be diagnosed through exam- 
ining the gastric contents. In these cases the latter no longer con- 
tains pure bile, but a yellowish brown, slightly feculent material, 
which has the appearance and composition of jejunal chyme. Care- 
ful examinations of this, but more especially its constant appearance 
in the stomach contents, should give us a clew to the existing con- 
dition, particularly if we can exclude a fistula between the stomach 
and the small or large intestines. We would add that, unlike 
deeply seated duodenal stenoses, the suprapapillary variety can not 
be diagnosticated by examinations of the stomach contents, for the 
latter are exactly the same as in benign or malignant pyloric stenosis. 

In some cases the determination of the acidity of the stomach 
contents may be important for the diagnosis of an intestinal affec- 
tion — e. g., in the differential diagnosis of ulcer of the duodenum 
and of the stomach. Leube 2 states that he found normal acidity of 
the stomach contents in a case of duodenal ulcer, while, from the 
investigations of Jaworski and Riegel, we know that the acidity in 

* It is well worth repeating, although obvious to one well acquainted with the 
subject, that the finding of bile once, or even repeatedly, in the gastric contents pos- 
sesses no diagnostic value. 



VALUE OF EXAMINATION OF THE STOMACH CONTENTS 131 

gastric ulcer is very often increased. Too much value, however, 
must not be attributed to this symptom. 

Oppler 3 has lately and quite correctly directed attention to the 
total cessation of gastric secretion in chronic diarrhoeas, a condition 
which has more of a practical than diagnostic value. As I can state 
from repeated personal experience in these cases, we may meet with 
severe forms of gastritis with entire absence of all the secretive 
factors (hydrochloric acid, pepsin, and rennet). I have no doubt 
that a distinct connection exists between the anacidity of the 
stomach and the chronic diarrhoea and intestinal catarrhs. 

The condition of the gastric contents indirectly aids us in under- 
standing certain intestinal disturbances, among others the chronic 
constipation that so often follows atony or ectasia of the stomach. 
In like manner, in displacements of the stomach, particularly when 
well marked, we can, as a rule, assume that a displacement of the 
intestine, especially of the large intestine, exists. The methods' by 
which these intestinal displacements can be recognized have already 
been described. 

LITERATURE 

1. Pulawski. Berl. klin. Wochenschr., 1892, No. 42. 

2. von Leube. Specielle Diagnose innere Krankheiten, 1889, S. 274. 

3. Oppler. Deutsch. med. Wochenschrift, 1896, No. 32. 



CHAPTEK VII 

THE DIAGNOSTIC VALUE OF URINARY EXAMINATIONS IN 
INTESTINAL DISEASE 

The examination of the urine is just as important in diseases of 
the intestines as it is in almost all other internal and many external 
diseases. It may in many cases substantiate and even clear up the 
diagnosis. Thus, to cite one instance, the discovery of an amyloid 
kidney may serve as a useful argument for the existence of amyloid 
disease of the intestines, a condition very difficult to diagnose. An 
attempt to dwell on all existing relations between the intestines and 
the urine would mean an account of almost the whole pathology of 
the urine. In the following recapitulation we confine our remarks 
solely to the clinical connection between intestinal diseases and cer- 
tain abnormal substances found in the urine. These substances in- 
clude : 

1. The products of intestinal putrefaction, especially of albu- 
minous putrefaction, the greater number of which, as we know, ap- 
pear in the urine as aromatic combinations. These include indoxyl- 
and skatoxylsulphuric acids, as well as the ethereal sulphuric acids 
(skatoxyl, parakresol, and phenol ethereal sulphuric acids). 

From the fundamental investigations of Jaffe \ E. Salkowski 2 , 
Baumann 3 , Brieger 4 , and Senator 5 , we know that the indoxyl- 
sulphuric acid of the urine is regarded as a derivative of the indol 
formed within the intestinal canal. In the intestines indol is 
already oxidized to indoxyl, and the latter combines with the sul- 
phuric acid, or with the sulphates derived from the food. Indoxyl- 
sulphuric acid (indican) appears in the urine in the form of the last- 
mentioned combination. From this it follows that indican is an 
entirely normal product of intestinal metabolism, and that only its 
increase is to be considered as pathological. Whereas the nor- 
mal daily excretion of indican varies from 5 to 20 milligrammes 
(Jaffe), in increased intestinal putrefaction it may reach 100 to 150 
milligrammes. Fr. Muller 6 and Ortweiler 7 very correctly con- 
132 



THE DIAGNOSTIC VALUE OP URINARY EXAMINATIONS 133 

sider as necessary for increase in the urinary excretion of indican 
a certain percentage of albumin within the intestines, marked 
stagnation of the intestinal contents, and finally a certain absorptive 
faculty on the part of the bowel. According to the animal experi- 
ments of Jaffe (which have been fully verified in man), increased 
excretion of indican occurs mainly in obstructions of the small, and 
to a less extent of the large, intestines. Nevertheless, we may also 
have an increased indican excretion in stenoses of the large intes- 
tines associated with long-continued putrefaction of their contents. 
Should suppuration coexist, the indicanuria will equal in amount 
that of the small intestines. 

As may be readily seen, increased indicanuria is largely depend- 
ent upon intestinal peristalsis ; other things being equal, the slower 
the peristalsis the greater will be the amount of indican in the urine, 
and vice versa. The more putrefactive products carried off by the 
intestines, the less will be brought to the kidneys. But this rule 
holds good only in a general sense : for Jaffe, Vries, Ortweiler, 
and von Pfungen (with whom Nothnagel agrees) have shown that 
there may be no indicanuria in obstinate constipation of the worst 
type. The reason very probably is that, in consequence of increased 
desiccation of the faeces, few putrefactive products are absorbed, 
and the faeces therefore very rapidly undergo further decomposition. 

The above considerations indicate that the presence of indican 
in the urine is of decisive value only when taken in connection with 
all other clinical symptoms. Indicanuria may be of importance in 
the differential diagnosis between stenoses of the large and small 
intestines, or between benign and malignant pyloric stenosis, etc. 
The almost constant increase of indican in suppurative peritonitis 
is also important. 

Besides indigo blue there is a second urinary colouring sub- 
stance, indigo red (" indigrubin," Kosin s ). Rosenbach's well-known 
reaction depends upon its presence. As shown by control tests of 
E. Salkowski 9 , C. A. Ewald 10 , Abraham 11 , Rumpel and Messter 12 , 
and others, Rosenbach's reaction, like a pronounced indigo-blue 
reaction, indicates nothing more than an increase in the excretion 
of indigo — i. e., albuminoid putrefaction. To a certain degree, the 
ethereal sulphuric acids of the urine are indicative of putrefaction. 
As with indoxyl, it has been shown that albuminoid putrefaction of 
stagnating intestinal contents is also an important factor in the pro- 
duction of the etherial sulphuric acids (E. Salkowski, C. A. Ewald, 
Baumann, Kast and Baas). A second undoubted factor is disturb- 
10 



134 DISEASES OF THE INTESTINES 

ances in function, such as occur in ileus, incarceration of the small 
intestines, lead colic, peritonitis, intestinal tuberculosis, and cholera. 
Finally, Brieger's 13 investigations have shown that in such acute 
infectious diseases as diphtheria, scarlet fever, and facial erysipelas 
there is an increase of ethereal sulphuric acids, while in typhoid, 
recurrent and intermittent fevers, variola, and meningitis there is a 
decrease. 

Increase in the ethereal sulphuric acids has also been observed 
in foul-smelling and putrid processes in various portions of the 
body. Furthermore, we may mention that even in healthy persons 
the amount of ethereal sulphuric acids excreted is subject to great 
fluctuations, and also that very much depends upon the nature of 
the food ingested. It therefore follows that the excretion of the 
ethereal sulphuric acids occurs under various conditions ; that it de- 
pends as much upon their formation within the intestines as it does 
upon their absorption ; furthermore, that it is to a large extent de- 
pendent upon the diet, and that even normally it is subject to the 
greatest variations. In the present status of the subject it would 
be very risky to form any positive diagnostic conclusion from an 
increased excretion of the ethereal sulphuric acids. Only where 
there is a marked abnormal increase can any conclusion be drawn, 
and then only in conjunction with other signs. 

2. Acetonuria and Diaceturia. — Petters 14 and Kaulich 15 pointed 
out the connection between digestive disorders and acetonuria. 
Later, Litten 16 described the occurrence of acetonuria in dyspeptic 
conditions. Acetonuria in diseases of the digestive tract has 
been most carefully studied by Lorenz 17 . He found this con- 
dition present in diseases of the stomach, as well as in the greatest 
variety of intestinal disorders — e. g., gastro-duodenal catarrh, 
gastro-enteritis, intestinal obstruction (from marked coprostasis), 
taenia, peritonitis, and perityphlitis. As fever was present in the 
last-named conditions, febrile acetonuria could not be positively ex- 
cluded. In almost all these cases, in addition to the aceton, diacetic 
acid was also found. At present no diagnostic significance can be 
attached to acetonuria. 

3. Albuminuria. — Maixner 18 and Pacanowski 19 first called atten- 
tion to the occurrence of an enteric peptonuria (more correctly 
albuminosuria), and Eobitschek 20 , who employed improved methods, 
confirmed their discovery ; nevertheless, the doctrine of an enteric 
albuminuria rests upon a very weak basis. Chvostek and Stro- 
mayr's 21 recently published investigations upon the occurrence of 



THE DIAGNOSTIC VALUE OP URINARY EXAMINATIONS 135 

alimentary albuminosuria in ulcerative intestinal tuberculosis are 
deserving of greater attention. A few hours after such patients had 
received large amounts of dry peptones or of somatose, albumoses 
were found in the urine, Devato's 22 and Salkowski' s ffl methods 
being employed for their detection. In some positive cases of 
ulcerative intestinal tuberculosis albumoses were not found, so that 
a diagnostic value can only be attached to a positive result of the 
test. 

LITERATURE 

1. Jaffe. Centralbl. f. d. medicin Wissenschaften, 1872, S. 481, and Virchow's 

Archiv, Bd. lxx, S. 72. 

2. E. Salkowski. Bericht d. deutsch. Chem. Gesellschaft, Bd. ix, S. 138 u. 

408. 

3. Baumann. Pfliiger's Archiv, Bd. xiii. 

4. Baumann u. Brieger. Zeitschr. f. physiol. Chemie, Bd. iii, S. 254. 

5. Senator. Centralbl. f. die medicin. Wissenschaften, 1877, S. 357. 

6. Fr. Mailer. Mittheilungen a. d. Wiirzburger Klinik, Bd. ii, S. 341. 

7. Ortweiler. Ibid., S. 153. 

8. Rosin. Virchow's Archiv, Bd. cxxiii, 1891, S. 519. 

9. E. Salkowski. Berl. klin. Wochenschr., 1889, No. 26. 

10. C. A. Ewald. Ibid., 1889, No. 44. 

11. Abraham. Ibid., 1890, No. 27. 

12. Rumpel u. Messter. Centralbl. f. klin. Med., 1891, S. 527. 

13. Brieger. Zeitschr. f. klin. Med., 1881, Bd. iii, S. 468. 

14. Petters. Prager Vierteljahrsschrift, 14. Jahrgang, 1857. 

15. Kaulich. Ibid., 17. Jahrgang, 1860. 

16. Litten. Zeitschr. f. klin. Med., Bd. vii, Supplemen theft, 1882. 

17. Lorenz. Ibid., Bd. xix, 1891, S. 19. 

18. Maixner. Zeitschr. f. klin. Med., Bd. viii, 1884, S. 534. 

19. Pacanowski. Ibid., Bd. ix, 1885, S. 428. 

20. Robitschek. Ibid., Bd. xxiv, 1894, S. 536. 

21. Chvostek u. Strohmayr. Wiener klin. Wochenschr., 1896, No. 47. 

22. Devoto. Zeitschr. f. physiol. Chemie, Bd. xv, Heft 5. 

23. Salkowski. Centralbl. f. d. medicin. Wissenschaften, 1894, No. 7. 



GENERAL THERAPEUTICS OE 
INTESTINAL DISEASES 

Non medicarnentis confidere sed iherapiee" — vox Liebermeister. 



CHAPTEK VIII 

TEE DIETETIC TREATMENT OF INTESTINAL DISEASES 

The fundamental principles laid down in the general section of 
my book on The Diagnosis and Treatment of Diseases of the Stom- 
ach apply equally to the general dietetic treatment of intestinal dis- 
eases. To avoid repetition, we refer the reader to that work. Sev- 
eral of the rules of procedure there described — e. g., those for the 
treatment of gastric ulcer and acute gastritis — may with slight 
changes be applied to cases of ulcer of the small intestine and acute 
enteritis. The conditions are, however, far more complicated in 
many other intestinal diseases. According to the pathological con- 
dition in the intestines, the stomach contents must have a varying 
influence upon the intestinal contents ; these latter are acted upon 
by three distinct secretions, each of which may vary in its effect 
upon the intestines. Absorption from the intestines and intestinal 
peristalsis may vary considerably. Some excrementitious substances 
from the blood exert an undoubted action on the intestines. 
Nervous and vaso-motor influences can hasten or retard digestion. 
From a consideration of all these conditions it is evident that intes- 
tinal digestion is a very complicated process. The principles of 
feeding in gastric affections are based to some extent on the results 
gained from an analysis of the stomach contents which can be 
readily obtained. On the other hand, we have as yet no satis- 
factory and practical general method of obtaining and analyzing 
the intestinal contents. Sometimes an idea of the changes which 
the food has undergone in the bowel may be gained from an 
analysis of the faeces. Hence the pathologist and physiologist 
have for many years paid great attention to the examination of the 
faeces. 

The first fundamental fact was discovered by Kubner, who 
showed that the digestion of food stuffs depends principally upon 
their chemical and physical composition. 

139 



140 DISEASES OF THE INTESTINES 

The following table is taken from Rubner's 1 work : 



Food stuffs. 



Meat 

Eggs 

Milk 

Milk and cheese 
White bread . . . 

Black bread 

Macaroni 

Indian corn 

Corn and cheese 

Hice 

Peas 

Potatoes 

Cabbage 

Carrots 



"WEIGHT OF SAME 


IN GRAMS. 


Fresh. 


Dried. 


884 


376 


984 


247 


2,470 


315 


2,490 


420 


860 


753 


1,360 


765 


695 


626 


750 


641 




780 


638 


552 


600 


521 


3,078 


819 


3,830 


406 


2,566 


352 



ABSORBED IN PER CENTS OF 



Dried 
substance. 


Albumin. 


Fat. 


Carbo- 
hydrates. 


95 


97 


95 




95 


97 


95 




92 


94-99 


95-97 


ioo 


94 


96 


97 


100 


95 


81 


. . 


99 


85 


68 




89 


96 


83 


94 


99 


93 


85 


83 


97 


96 


93 


91 


96 


96 


80 


93 


99 


91 


83 




96 


91 


68 


96 


92 


85 


82 


94 


85 


79 


61 


94 


82 



Ash. 

82 
82 
51 
74 
93 
64 
76 
70 
81 
85 
68 
84 
81 
76 



This table is very instructive in that it shows that the albumi- 
nous substances contained in meat, eggs, and milk are almost totally 
used up in the intestines. ISTone of the vegetable matters, with the 
exception of Indian corn, are so completely absorbed. Yery little 
of black bread, potatoes, and carrots is absorbed. The greater part 
of the carbohydrate materials is, however, absorbed in the intes- 
tines. Thus milk loses 100 per cent ; white bread, macaroni, In- 
dian corn, rice, and peas almost as much ; potatoes and carrots lose 
little of their carbohydrate matters in the intestinal canal. Intes- 
tinal absorption of the fatty matters is also very active ; thus milk 
loses very much of its fat, as do also meat, eggs, macaroni, rice, 
potatoes, cabbage, and carrots. 

The digestibility of food stuffs can be further heightened by the 
manner of preparing them. Thus, according to Kubner, Boeck, 
Praussnitz, Weiske, and others, 72 per cent of the albuminous mat- 
ters are absorbed in the intestine from boiled peas as against 82 per 
cent from ground-up peas, and 68 per cent of boiled potatoes as 
against 80 per cent of mashed boiled potatoes. The addition of 
spices to the food is also of undoubted benefit in this respect. The 
above-mentioned figures apply only to healthy persons. Unfortu- 
nately, our knowledge of the digestibility of food stuffs in diseased 
individuals is very limited. The investigations of Fr. Muller 2 , so 
frequently referred to, have shown that in intestinal diseases the 
absorption of fats is early disturbed, and the absorption of nitroge- 
nous matters is interfered with only in some intestinal catarrhs. 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 141 

The absorption of carbohydrates is almost never interfered with, 
although it is probable that some of the carbohydrates are lost 
through fermentative processes in the intestines. 

The food stuffs exert an important influence upon many of the 
intestinal putrefactive processes. Thus Rubner 1 observed that 
after a diet of bread the products of albuminoid putrefaction dis- 
appeared from the urine, and in their stead there appeared a butyric 
acid fermentation. 

Hirschler 3 demonstrated that a direct antagonism existed be- 
tween albumin and carbohydrate putrefaction. Ortweiler 4 showed 
that a free diet of carbohydrates is apt to be followed by the com- 
plete disappearance of indican from the urine. It is evident that 
the food stuffs vary in their proneness to decomposition, and that 
in disease there may be a greater or less tendency for the occur- 
rence of putrefactive processes of the albuminous, carbohydrate, 
or fatty matters. Unfortunately, our knowledge of the principles 
of dietetics is so meagre that no deductions can be drawn from this. 

In the absorption of food stuffs from the diseased intestine an- 
other factor is of importance, viz., the influence exerted by the food 
upon the intestinal functions. Thus, for example, in some diseases 
of the intestines milk causes constipation, in others diarrhoea. Eggs, 
to take another example, are not well borne in diarrhoea, but are 
always prone to cause flatulence. The idea that some substances 
are easier digestible and others not so is gradually losing many ad- 
herents, for we are gradually coming to the conclusion that the 
digestibility of foods varies in each individual case. This illustrates 
the uselessness of basing our dietetic measures solely upon the diges- 
tibility of various foods. Clinical experience must teach us the 
principles of dietetics. From my observations and those of others 
the following rules may be laid down : 

1. In a number of intestinal diseases a change of diet is un- 
necessary, or may even be harmful. 

2. In some cases special dietetic restrictions are directly indi- 
cated, but these should be as few as possible. 

3. In another series of cases an abundant heavy, not easily diges- 
tible or absorbable diet is indicated. 

4. The general aim of our treatment should always be to so 
manage the case before us that digestion of a normal diet will 
always occur in the alimentary canal without any subjective or ob- 
jective disturbances. Under these circumstances only can the case 
be considered cured. 



142 DISEASES OF THE INTESTINES 

The reasons which have led me to adopt the above principles of 
treatment will be given in what follows, which will contain a gen- 
eral description of the principles of feeding in diseases of the intes- 
tines. For simplicity of understanding, intestinal diseases are classi- 
fied * as 

1. Diseases of the mucous membrane (ulcers of the duodenum, 
jejunum and ileum, acute and chronic enteritis, carcinoma, intestinal 
ulcers in general). 

2. Functional disturbances (increased or diminished peristalsis). 

3. Stenosis or occlusions. 

4. Localized peritonitis (appendicitis) ; diffused peritonitis. 

5. Neuroses. 

1. Diseases of the Intestinal Mucous Membrane 

In diseases of the mucous membrane the principles of feeding 
are similar to those laid down for the treatment of affections of the 
body in general — i. e., rest for the affected part. The temporary 
withdrawal of all foods constitutes the greatest possible amount of 
rest for the digestive tract, and one that is often followed by bril- 
liant therapeutic results. This method comes up for a special con- 
sideration in acute bleeding from the stomach or intestines, in acute 
gastro- enteritis, and in rebellious forms of gastric or duodenal ulcer- 
ation. The importance of the latter disease is worthy of special 
consideration in this place. That the absolute withdrawal of food 
is the best therapeutic measure in acute intestinal haemorrhage 
(exclusive of bleeding from haemorrhoids) is not as yet, according 
to my experience, generally acknowledged. I emphasize the word 
absolute, because I believe that in these cases even water by the 
mouth is harmful. In such a patient the physician, and especially 
the relatives and friends, are but too apt to give the patient large 
quantities of fluid to drink to compensate for what has been lost 
by the bleeding — a procedure which I consider absolutely wrong. 
Food should not be given by the mouth until twenty-four to thirty- 
six hours after the haemorrhage has ceased. By that time the 
bleeding vessels have probably been closed by a thrombus. If the 
weakness of the patient calls for immediate feeding, nutrient ene- 

* In this classification it may occur that some diseases might, during their 
course, come under another heading than they would at first ; thus, a carcinoma 
of the intestines might be at first considered a disease of the mucous membrane, 
later, as the symptoms of obstruction come to the foreground, as a stenosis. The 
same is true of many other intestinal affections. 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 143 

mata should be ordered.* During the following few days the 
patient should be kept on a fluid diet. After eight to ten days 
the diet may be gradually increased according to the well-known 
plan of Leube. 

In acute haemorrhage from the large intestines (as in haemor- 
rhoids, dysenteric ulcers, and neoplasms) the danger of profuse 
bleeding is not great, and hence the entire withdrawal of food is 
unnecessary. It will generally suffice to restrict the patient to a 
soup diet for a few days. 

In chronic bleedings, which are apt to be small ones, it is very 
important so to arrange the patient's diet as to prevent the symptoms 
of exhaustion which are apt to appear. The choice will largely 
depend upon the nature and character of the illness. In the spe- 
cial part of the present work more attention will be paid to this 
subject. 

In violent haemorrhages from large blood-vessels (embolism of 
the mesenteric artery, rupture of varicose veins, etc.) we are 
usually powerless. Diet has but little influence upon these haemor- 
rhages. 

The treatment of acute gastro-enteritis or enteritis alone is far 
simpler. In these affections the loss of appetite facilitates the 
withdrawal of food. In very acute diarrhoeas we must provide 
against the severe thirst which is so apt to be present, by giving the 
patient diluted claret, oatmeal soups, cocoa boiled in water, and tea 
without sugar. In chronic duodenal ulceration the same diet as in 
gastric ulcer is to be ordered. The patient should remain in bed 
for several weeks, poultices should be applied to the abdomen, and 
he should partake of a bread -and-milk diet. This diet should be 
continued until subjective and objective sensitiveness have disap- 
peared, when the patient should abstain for a long time from inju- 
rious diet — that is, food digested with difficulty (ice cream and iced 
dishes, raw fruit, hard bread, all kinds of cabbage) — and improper 
drinks (iced drinks, acid fruit juices, carbonated beverages). 

In very obstinate forms of duodenal or jejunal ulceration the 
treatment is similar to that of gastric ulceration — i. e., abstinence 
from all food for ten to fourteen days, and rectal alimentation. In 
nine undoubted cases of this class I found that the above-outlined 
treatment was always sufficient. 

* Concerning the composition and method of giving nutrient enemata, see 
Boas, Diagnosis and Treatment of Diseases of the Stomach, fourth edition, 
Part I, p. 293. 



144 DISEASES OF THE INTESTINES 

The diet in chronic enteritis varies greatly, according to the sit- 
uation, intensity, extent, and duration of the disease. It is diffi- 
cult, therefore, to lay down any general rules, and we will limit 
ourselves to a few suggestions, reserving fuller details for the second 
part of this work. The treatment will depend mainly upon our 
being able to locate the intestinal catarrh. 

Catarrhal affections of the small intestines call for a particularly 
cautious diet. In long-standing diseases it is clear that the intesti- 
nal secretions are deficient in quality, and hence can not act in a 
normal manner upon the chyme. It can be readily understood that 
if, in place of the normal strongly alkaline intestinal juice, a weakly 
alkaline one containing large quantities of mucus is secreted (in 
which cases the acidity of the chyme is not sufficiently neutralized), 
the pancreatic juice will be acted on in an abnormal manner. In 
the presence of the strong acidity the pancreatic juice loses its tryp- 
tic, diastatic, and fat-splitting properties ; the emulsification of fats 
is delayed, or does not at all take place ; the action of the bile is 
likewise interfered with by the hyperacidity of the small intestines. 
Where, as is usually the case in intestinal catarrh, there is diarrhoea, 
the greatest care must be exercised in the selection of a suitable 
diet. If the diet does not contain sufficient nourishment, the 
patient may suffer from a transitory loss of albumin. Neverthe- 
less, this plan must be carried out. The more numerous the 
evacuations, the greater is the need for restriction of the diet. In 
the beginning, gruel, cocoa, tea, beef tea, nutrose,* and claret, or 
cognac diluted with water, may be ordered for the patient. The 
diet must be varied according to the number and consistency of 
the movements. Regarding a diet of milk and eggs in diarrhoea, 
the most important facts have already been given ; as the patient 
improves, an egg may be stirred into the soup, and according to 
the manner in which the patient stands this the diet can be still fur- 
ther increased. We may then gradually let the patient take milk. 
Its effects should be carefully noted ; very often it will have to be 
entirely excluded. It is obvious that all substances that increase 
peristaltic motion (fruit, cider, certain wines, [organic] acids, honey, 
sugar) must be avoided. It is not correct, however, as is still often 
done, to give general instructions according to the above-mentioned 
principles. Exact instructions as to the diet must be given in 

treating each individual case. 

* ■ 

* In all diarrhceal conditions somatose must be avoided, because it is apt to 
aggravate them. 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 145 

In catarrh of the large intestine dietetic principles are quite 
different. There is present either constipation, or constipation 
alternating with diarrhoea, or diarrhoea alone. In the last-named 
variety the diet is the same as that of catarrh of the small intes- 
tines. In the other forms our aim should be to regulate the move- 
ments without injury to the inflamed intestinal mucous membrane. 
In these cases digestion in the stomach and the small intestines is 
usually normal, and therefore the patient may from the very begin- 
ning be placed upon a full and nourishing diet. We may begin 
with a free diet (meat, fish well prepared, soft-boiled eggs, fat such 
as butter, chicken fat, cocoa butter). Vegetables in puree form and 
carefully prepared pastry may also be allowed. Conversely, experi- 
ence has shown that soups tend to arrest peristalsis ; they, as well as 
other physiological astringents (rice, farina, cocoa, red wine, huc- 
kleberry wine, etc.), are to be avoided. Physiological laxatives 
(honey, milk, sugar, glucose, grapes, stewed fruits, and sweet pas- 
try) are especially to be recommended. In these cases milk, and 
particularly such of its derivatives as contain acids (buttermilk, 
koumyss, sour milk), may be employed to great advantage. We 
should strictly forbid the use of all substances which from experi- 
ence resist all action of the intestinal secretions, such as the cellu- 
lose of cabbage, beets, and root vegetables, as well as indigestible 
seeds which are contained in many fruits (huckleberries, cranber- 
ries, currants, and gooseberries). A very similar diet is to be 
ordered in that form of intestinal catarrh that manifests itself in 
diarrhoea alternating with constipation, for here the constipation 
must be looked upon as the predominant and primary factor. In 
these cases our judgment of the results of the treatment instituted 
should not be governed by the effect upon the constipation alone, 
but from the appearance of the evacuations, and particularly from 
the amount of mucus contained in them. At the same time the 
above-named general principles must not be lost sight of. In pri- 
mary catarrhs of the lowermost portion of the intestine (sigmoid 
flexure and rectum) the same general principles also apply. 

In secondary catarrh, we may under favourable circumstances 
achieve successful results by removing the cause of the congestion 
in the intestinal blood-vessels. Generally we will have to content 
ourselves with a symptomatic treatment of the intestinal disturb- 
ances, following the above-mentioned underlying principles. 

The dietetic treatment of intestinal ulcers also varies much, 
according to their nature and situation and the influence winch they 



146 DISEASES OF THE INTESTINES 

exercise upon the movements. Thus, according to Nothnagel, 
ulcers of the small intestine or of the ascending colon only cause 
diarrhoea when they occur simultaneously with other conditions 
(catarrh, amyloid disease, etc.), while ulcers of the lower division 
of the large intestine are usually accompanied by diarrhoea. Natu- 
rally the diet in ulceration of the upper portions of the small intes- 
tines will have to be a very cautious but highly nutritive one, and 
in ulcers of the lower portions of the small intestine we should by 
all means avoid all irritation of the mucous membrane from indi- 
gestible food masses. For the rest, the condition of the evacuations 
(consistency, number, admixtures such as pus, blood, etc.) will have 
to guide us in the choice of the diet. 

As regards tumours, the malignant ones alone require special 
dietetic measures. We will have to take into consideration the pres- 
ervation of the patient's life, and, if possible, the improvement 
of his general condition, the local (intestinal) damage (secondary 
catarrh, stenosis). Since our dietetic measures will ultimately de- 
pend upon these complications, they will, to avoid repetition, be 
detailed in the section on " Intestinal Stenosis " (Part II). 

2. Diet in Functional Disturbances of the Intestines 
(Retardation or A cceleration of Peristalsis) 

Under this heading, in the first place, we include habitual con- 
stipation and habitual diarrhoea. Both conditions may be accom- 
panying symptoms of other diseases, or they may occur as inde- 
pendent functional intestinal disturbances : they therefore deserve 
to be discussed separately. In the second portion of this work fur- 
ther consideration will be paid to this subject ; in the present place 
we wish to discuss the dietetic treatment of simple, uncomplicated 
constipation and diarrhoea. 

In habitual constipation the diet must be a plentiful as well as a 
mixed one, and should contain substances that are known to stimu- 
late peristalsis. Conversely, as already stated, dietetic astringents 
must be avoided. The first indication is frequently disregarded. 
We have already seen that foodstuffs are divisible into those well 
utilized and those poorly utilized by the economy. The first group 
includes all fluids and substances dissolved in them, meat, fish, 
wheaten bread and the like, light pastry, etc. The second group 
includes those foodstuffs that leave more or less of an indigestible 
residue — as, for example, fruit, rye bread, cabbage, potatoes, salad, 
and other vegetables rich in cellulose. 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 147 

The main feature in the treatment of habitual constipation is 
the employment of this last-named variety of foodstuffs. Were a 
vegetable diet as nutritious as a mixed diet, and were its exclusive 
employment not frequently associated with objective (gastric and 
intestinal dilatation) and subjective disturbances (abnormal flatu- 
lence), it would be the ideal one in constipation, since it leaves 
behind a considerable indigestible residue. In general, therefore, 
sufferers from constipation should be given a mixed diet containing 
a minimum amount of totally digestible foodstuffs and a preponder- 
ance of those that contain much indigestible material. With such 
a regime we may accomplish much, but not all we wish to. The so- 
called " physiological laxatives " must also be given. We know a 
number of them ; they act either chemically or thermically. The 
chemical ones include the organic acids, the mineral salts, and 
numerous sugars as well as fats. The organic acids include lactic, 
butyric, acetic, and probably also a number of other acids devel- 
oped in the body from carbohydrates (formic, caproic, caprylic, pro- 
prionic acids, etc.). As the investigations of A. Bokai 5 have shown, 
these acids are important factors in peristaltic action. It is a ques- 
tion whether the acids introduced as such, or those which develop 
from fermentation in the intestines, are the main causes of normal 
peristalsis ; for many reasons the latter variety should be regarded 
as the main cause. It is certain, however, that these acids do excite 
intestinal peristalsis very strongly — more strongly, for example, than 
do many vegetable cathartics. 

Among the foods which contain these acids are buttermilk, sour 
milk, kefir, and koumyss. In the latter two substances the carbonic- 
acid gas is also an efficient factor, for this gas excites intestinal 
peristalsis. 

We know from animal experiments and observations upon man 
that the mineral salts also stimulate peristalsis. Upon this fact are 
based our ideas of the action of the muriated and Glauber salts. 
This has taught us to give patients suffering from habitual con- 
stipation plentifully salted food, such as sardelles, herring, caviar, 
smoked and boiled ham, and smoked beef. 

The sugars have long been known as home remedies in habitual 
constipation. The sugars have not, however, a common action on 
the organism. Thus milk sugar, and probably also levulose and 
dextrose, have a greater influence upon peristalsis than has cane 
sugar. The physiological action of the sugars may be due to either 
the products of the decomposition of sugar in the body — i. e., lactic 



148 DISEASES OF THE INTESTINES 

acid, butyric acid, acetic acid, etc. — or the sugars may exert an influ- 
ence upon the intestinal mucous membrane by causing an active 
transudation from it. The investigations of Strauss 6 have shown 
that after the ingestion of sugar considerable transudation from the 
gastric mucous membrane occurs — a condition which I found pres- 
ent years ago in experiments on the gastric digestion of sugars. 

The sugars have, therefore, a similar action to the saline cathar- 
tics (magnesium sulphate, sodium sulphate). Any one of a large 
variety of saccharin foodstuffs can be made use of instead of sugar 
itself. Among these may be mentioned sweet fruits, grapes, honey, 
sweet milk (also that sweetened with milk sugar), condensed milk, 
sweet wines (Tokay, Marsala, Sauterne, pasteurized grape juice, 
young wine, etc.). 

Finally, the thermic methods should be mentioned. It is a fact 
of daily observation that cold applied externally or internally stimu- 
lates peristaltic action. Many of the laity, being cognizant of this 
result, are accustomed to drink cold water on an empty stomach in 
order to stimulate the activity of the bowels. It is advisable, there- 
fore, in these cases to order cold instead of warm or hot, and prefer- 
ably fruit soups, cold tea, coffee, sweetened lemonade, etc. 

By means of these substances we are able to increase the intes- 
tinal activity at will. In rebellious cases of constipation one must 
not, as is so often done, expect too much from one particular 
remedy. Since these agents are adjuncts one to the other they 
must often be combined. I am accustomed to name a diet of this 
kind a " constipation diet," and I shall speak of it more in detail in 
the second part of this work. In the selection of appropriate food, 
the location of the trouble, its duration, and the condition of the 
patient have to be considered, but the principles upon which this 
diet of constipation is based must never be lost sight of, and always 
be applied in the proper manner. 

As already stated (page 145), it is of prime importance to 
exclude all physiologically constipating remedies from the diet. 
Thus I have often seen patients for whom the diet had been pre- 
scribed correctly in all respects, except that they were allowed to 
partake of one half or even one bottle of claret daily — an absurd 
allowance. For similar reasons, cocoa, rice, farina, and foods pre- 
pared from flour, unless freely sweetened with sugar, should t>e 
forbidden. I have little doubt that a diet based on principles as 
above described and varied for each individual case, will result in 
a permanent cure of even rebellious and long-standing cases of 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 149 

constipation — a cure which will satisfy the conditions already 
mentioned (page 141), that even with ordinary diet the bowels 
will move in a normal manner. In those cases where the 
patients have been dosed with cathartics many years, only a care- 
fully prescribed diet, strictly followed out for years, may result 
in a cure. 

Besides the regulation of the diet, other therapeutic measures 
have to be observed in habitual constipation. Of equal importance 
are the regulation of the amount of exercise, stated hours for meals, 
a regular and sufficiently long time for defecation, a stimulation of 
the weakness of the intestinal nruscle by exercise of the muscles in 
general, in particular those of the abdominal wall, etc. These con- 
siderations belong rather to the special treatment of habitual consti- 
pation, and will be discussed in detail in the second part of this 
work. 

The choice of diet in chronic diarrhoea depends, as has been 
mentioned above (page 144\ upon the number and consistency of 
movements and the duration of the affection. The most important 
principles of treatment have already been considered in speaking 
of catarrh of the small intestine. The mechanical, chemical, and 
thermal agents which stimulate peristaltic action in habitnal consti- 
pation have, on the other hand, an unfavourable influence on diar- 
rhoea. In regard to the first agent mentioned, we would therefore 
carefully avoid all coarse, indigestible, or not easily digested sub- 
stances, and particularly those containing much cellulose, such as 
cabbage, salad, pickles, beets, and other root vegetables. Of the 
chemical agents, all organic acids and sugar are to be avoided. 
Where the food or drink has to be sweetened, it is best to use sac- 
charin — a substance which Gans 7 , in his investigations made in my 
laboratorv many years ago, showed was also to a certain degree an 
intestinal antiseptic. That good fats even in large quantities are 
generally weU borne in chronic diarrhoea, is worthy of mention. 
Experience has taught me that even in severe cases one can prevent 
exhaustion hy adding fats to the food. All cold drinks, ice water, 
seltzer water, and other carbonized beverages (beer, champagne, 
etc.), and even cold water, should be avoided. Hot drinks, on the 
contrary (tea, soups, and claret), have a tendency to diminish peri- 
stalsis. As has been mentioned on page 144, milk is not, as a rule, 
well borne, and is apt to increase the number of stools. Cold milk 
has a very unfavourable influence on diarrhoea, while hot milk may 
not be harmful. Sometimes milk even in large quantities is well 
11 



150 DISEASES OF THE INTESTINES 

borne when cognac, limewater, powdered lime, talcum, ground bar- 
ley, rice, Indian meal, or oatmeal, etc., are added to it. In a very 
few but convincing cases I have seen good results from systematic 
milk cures, and I believe that a careful trial may be made of them. 
It is hardly necessary to add that in these cases salts (table salt, 
nitre, and other spices) should be forbidden. If eggs (even 
poached) or foods containing them are not well borne they should 
be excluded from the diet. Generally, at least in the beginning 
of the treatment, eggs should be sparingly or not at all given. 

In addition, those kinds of foods or drinks should be recom- 
mended which from experience, or from whose composition, we 
know tend to lessen peristaltic activity. In this category we may 
mention the cereals which contain much mucin (farina, rice, barley, 
oatmeal, porridge, etc.). These may be ordered in the form of soups, 
or, better, as thick, unsweetened gruels.* Other articles of diet 
which should be mentioned here are those which are characterized 
by containing more or less tannic acid. Among these may be men- 
tioned " eichel cacao," " eichel coffee," infusion of nut leaves (e. g., 
butternut), of bearberry leaves (folia uva ursi), decoctions and jel- 
lies of fresh huckleberries, and a number of red wines containing 
much tannin, of which huckleberry wine is most useful. 

A good old Bordeaux wine, the Greek wines (particularly Cama- 
rete), the Italian red wines, and Simaruba wine may be also 
given. 

If the patient will adhere strictly to this diet not only during 
the whole course of treatment, but even, though not so strictly, for 
many months thereafter, his intestinal disturbances may be much 
improved or entirely cured. In modern society, with its dissipation 
and excesses, this plan of treatment will be adhered to only by a 
small proportion of the patients. Diet, however, is not all-suffi- 
cient. It must be remembered that other conditions (cold, consti- 
tutional disturbances, sexual excesses, overexertion) may have con- 
siderable influence upon the affection. This will be treated of more 
in detail in Part II of this book. 

3. The Diet in Chronic Stenosis and Obstruction of the 

Intestines 

Chronic stenosis occurs in different portions of the intestine, 
either as a benign (adhesive peritonitis, contracting scars of ulcers, 

* In these cases saccharin may be used with much advantage instead of sugar. 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 151 

benign tumours) or as a malignant process (carcinoma, sarcoma). 
No matter where the location of the disease and how great its 
severity, the main therapeutic object must consist in the removal 
of the causal factor. Diet will naturally have some influence upon 
this. Even if its location be recognised, we are often able to remove 
the cause of the obstruction only by operative means ; still, the 
proper regulation of the diet may contribute much toward amelio- 
rating or removing subjective or objective symptoms. In such cases 
two points have to be considered before beginning the feeding : the 
location and the degree of the obstruction. The location of the 
disease may be discovered in many if not all of the cases. The 
severity of the symptoms, the shape, consistency of the stools, the 
visible or palpable peristaltic restlessness and intestinal rigidity 
(Nothnagel), the appearance of meteorism, vomiting, etc. — all 
these signs and symptoms indicate, though sometimes falsely, the 
amount of obstruction. Since there are always processes of putre- 
faction above the stenosed portion of the intestine, the direct bear- 
ing of the amount of obstruction upon the diet to be prescribed is 
not to be underestimated. The diet will differ according to situa- 
tion of the obstruction in the large or in the small intestine. The 
chyme remains fluid or semifluid until it reaches the lowest part 
of the ileum, and hence can pass through a greater obstruction here 
than below this point. Abnormal processes of fermentation and 
putrefaction are less apt to occur. The diet should be so arranged, 
therefore, that only fluids or foods prepared in liquid form are 
taken, while solid, indigestible, or not easily soluble matters are 
to be avoided as far as possible. It is hardly necessary to point out 
that food that ferments easily, or is already in a state of fermenta- 
tion, should be excluded from the diet. 

When the obstruction lies in the large intestine the conditions 
are far more complicated. In this part of the bowel the fseces lose 
most of their water, and in conditions of obstruction this loss of 
water is further increased because of the lack of fluid in the sur- 
rounding tissues. It matters not how large an amount of fluid the 
patient imbibes, the faeces are always firm when they reach the 
site of obstruction. One often has to ask himself the question 
whether it might not be advisable to order solid instead of liquid 
food. Under a solid diet, however, there might be danger of 
increased fermentation and putrefaction because of the large quan- 
tities of easily putrefactive material which would reach the site of 
obstruction, and furthermore, on account of the spasmodic peristal- 



152 DISEASES OF THE INTESTINES 

sis, solid indigestible substances might become lodged in the stenosed 
portion of the bowel. Lentils, peas, beans, asparagus, fruit, etc., in 
short, those vegetables which contain much cellulose, would be most 
apt to create such a condition — one very similar to that which occurs 
in a typical manner in stenosis of the pylorus. A number of cases 
have been reported in which moderate errors of diet have caused a 
decided increase or an acute exacerbation of mild or quiescent 
symptoms. 

The diet in stenosis of the large intestines will therefore have 
to be based on the following principles : 1. It should contain a 
plentiful amount of solid material. 2. These solid materials must 
be free from mechanically irritating ingredients. 3. The diet must 
contain laxative ingredients. 4. These must not be excessively prone 
to undergo fermentation. The first two points need no explana- 
tion ; some attention must, however, be paid to the last two. That 
substances which tend to make the stools less solid are advan- 
tageously added to the diet has been already clearly shown (page 
147). Unfortunately, however, some of these substances, and among 
them the sugars, form a good substratum for the occurrence of fer- 
mentative processes above the site of the obstruction ; hence they 
must be avoided. Experience has taught me that organic fatty acids 
and the acids of fruits are generally well borne. The same is true 
of salts, which probably diminish and certainly do not increase fer- 
mentation in the intestinal canal. A plan of diet based on such 
principles may be given in short resume in the following : Mixed 
food — meat, fish, vegetables, etc. — should be prepared in puree 
form ; well-salted and pickled meat or fish are especially recom- 
mended. Fat may be given in moderate quantities. Sweet milk is 
not well borne, but buttermilk, thickened milk, kefir (free from 
carbonic acid and two days old), koumyss (free from carbonic acid) 
are permissible. No, or only small quantities of, sweet stewed 
fruit, in which saccharin may be used instead of sugar, should be 
allowed. A diet suitable for each individual case may be con- 
structed on these principles. It is of prime importance to counter- 
act the tendency to severe grades of constipation ; and if, as is often 
the case, the regulation of the diet will not suffice, one must occa- 
sionally order mild vegetable laxatives. It would be a palpable 
error to order a constipating diet for — or, what is still worse, to give 
opiates to — a patient who has partial intestinal obstruction. An 
exception to this statement is furnished by those cases of spas- 
modic tetanic intestinal peristalsis, in which opium not only quiets 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 153 

the contractions, but even acts as a laxative. This subject will, 
however, be treated of in another place. 

The diet to be used in complete intestinal obstruction differs 
essentially from that in partial obstruction. In complete obstruction 
the diet must be very limited. Obviously this is of paramount 
importance when the obstruction is in the small intestines, for in 
these cases the entry of food into the stomach or intestines causes 
immediate vomiting. When the obstruction is in the large intes- 
tines (invagination, volvulus, foreign bodies, fsecal impaction) this is 
also, though in a less degree, true. Only small quantities of very 
easily digestible foods, preferably fluids, should be given at long 
intervals, and, when possible, nourishment by some other path 
should be at once begun (nutrient enemata, subcutaneous saline 
infusion, salt-water enemata). Weakness, with cardiac exhaustion, 
is to be greatly feared, since it will prevent the one therapeutic 
curative method in the disease, namely, operation. 

When the obstruction is in the small intestine, or in the upper 
part of the large intestine, the patient should be given nutrient 
enemata. If in the lowermost portion of the large intestine or the 
rectum, the best one can do is to attempt to prevent threatening 
collapse by injections of salt or glucose under the skin. In most 
of the cases the result is unfavourable unless surgical aid is early 
called in. 

4. The Diet in Typhlitis and Appendicitis 

By appendicitis we mean those inflammations which start from 
the appendix vermiformis and either remain localized or extend to 
the peritoneum or retroperitoneal cellular tissue, or through perfo- 
ration attack a part or the whole of the peritoneal cavity. A pri- 
mary typhlitis caused by fsecal impaction or foreign bodies, and 
often followed by perityphlitis with its symptoms, does occur. 
With this short statement of my position on an affection which has 
been the cause of much clinical difference of opinion, I shall close 
this subject and turn to the dietetic treatment of the condition, 
reserving the details for discussion in another place. 

It is exceedingly difficult to lay down any general rules of diet, 
because in these affections the food must vary with the character, 
severity, and course of the disease, as well as with the varying com- 
plications and relapses. In stercoral typhlitis the question is easy ; 
in appendicitis it is more difficult. For simplicity, I think it best 
to adhere to the classificatioi? proposed by Sonnenburg, into the 



154: DISEASES OF THE INTESTINES 

catarrhal, the perforative, and the gangrenous forms of appendi- 
citis. 

In typhlitis due to fsecal impaction the diet must be so arranged 
as to aid in the softening and discharge of the faeces. The use of 
laxatives (castor oil) or of enemata can be advantageously combined 
with a suitable diet. 

In most cases catarrhal appendicitis gets well of its own accord, 
and the treatment must be so directed as neither to irritate the 
intestines mechanically nor to increase peristalsis. This is best 
accomplished by means of a fluid diet, continued until the rise of 
temperature, the exudate, and the sensitiveness to pressure in the 
ileo-c83cal region have disappeared. Judging from my experience, 
I believe that Sahli 8 , Quincke 9 , and Penzoldt 10 are too extreme 
when they recommend that for one or more days all food should 
be at once withdrawn. 

After the acute inflammatory symptoms have disappeared, we 
may for the next week allow the patient, in addition to fluids, to 
partake of gruels (rice, barley gruels, vegetables in puree form, etc.). 
After another week meat, beginning with the tender varieties, may 
be added, together with foods made of flour and various stewed and 
preserved fruits. After four weeks have elapsed the patient may 
return to his normal diet, which should be so arranged as to coun- 
teract the tendency to constipation which is always present in these 
cases. 

In the second variety, the suppurative form of appendicitis, the 
danger to life is much greater, and the main question is when 
to interfere surgically. Diet is of secondary importance. Even 
in these patients I do not believe that an absolute withdrawal of 
food is advisable, because, on account of the high fever, the patients 
generally suffer from severe thirst. Penzoldt permits his patients 
to drink water, and hence I do not see why they may not also take 
small quantities of tea, milk, wine, and gruels. It seems to me that 
the fear of a " dangerous stimulation " of peristalsis is exaggerated, 
all the more as the opium treatment is more thoroughly carried 
out.* This does not mean, of course, that one should not withdraw 
all feeding by the mouth where there is severe vomiting or symp- 
toms of intestinal obstruction, and use in its stead frequently 
repeated nutrient enemata. In general, however, in acute or sup- 

* [Within recent years, here in the United States, routine opium treatment — for- 
merly so popular — has been almost entirely abandoned, even in those cases treated 
without operation. — Tr.] 



THE DIETETIC TREATMENT OF INTESTINAL DISEASES 155 

purative stages of the affection, rectal alimentation must be desisted 
from, if possible, since it necessitates moving the patient about and 
naturally disturbs the inflamed intestine. If the critical stage of 
the disease is passed, or if an operation has freed the patient from 
danger, the diet must be arranged according to the principles above 
mentioned. 

The same general principles apply also to the gangrenous variety 
of the disease, but the diet must be still more carefully managed. 
The bowels should be regulated, and by this means the occurrence 
of relapses prevented. Only in very resistant cases should laxatives 
be made use of, and one should endeavour to regulate the bowels by 
means of the appropriate diet for constipation which has already 
been described. 

As the rarer forms of tubercular and actinomycotic appendicitis 
do not differ essentially from the forms above described, it will be 
unnecessary to detail the principles of feeding in these cases. 

5. The Diet in Intestinal Neuroses 

The practical importance of the dietetic treatment of intestinal 
neuroses is that by its means we may improve the general condition 
of the patient or remove prominent symptoms of the affection (con- 
stipation, diarrhoea, pain, flatulence, etc.). If the diagnosis is abso- 
lutely certain, it is questionable whether any special regime is neces- 
sary at all. Many errors are made in this direction. I have seen, 
for example, a strict diet cause or increase constipation, tympanites, 
and colic, which symptoms had presented almost a typical picture 
of nervous dyspepsia. Such patients tell us that they can not even 
partake of soup without being troubled with belching or with severe 
tympanites and abdominal pain. Often the patient will be imme- 
diately cured by partaking of a full diet. I would therefore 
emphatically warn physicians against restricting the diet too quickly 
when they have patients who complain of intestinal symptoms with- 
out discoverable physical signs. In some cases, as in the so-called 
nervous diarrhoea, this is to some extent necessary. But even in 
these cases one should in some degree be guided by the sensations 
of the patient, and should not order all possible sorts of restrictions 
at once. The patients may make strange assertions which contra- 
dict all the acknowledged laws of physiology and pathology, but 
these statements must not be absolutely ignored.* 

* Thus, I have a patient in whom even the best kind of claret always causes 
diarrhoea, although Moselle wine promptly counteracts the effect of the red wine. 



156 DISEASES OF THE INTESTINES 

This class of patients is best treated in a sanitarium, where 
observation will soon show the appropriate diet for the indi- 
vidual case. 

The treatment of nervous flatulence — a condition whose treat- 
ment, in the experience of every busy practitioner, gives very unsat- 
isfactory therapeutic results — must be considered in this place. 
The attempt to determine the cause of the flatulence meets with 
many difficulties. In more than one case, even after long obser- 
vation, I have been in doubt as to the nature of the process, and 
more especially whether or not there was abnormal fermentation in 
the intestines. Not only do the patients not improve under strict 
dietetic treatment, but they often become distinctly worse. Tym- 
panites and constipation, when they occur together, may be regu- 
lated by an appropriate but not a bland diet ; diarrhoea may, how- 
ever, be accompanied by tympanites, and a constipating diet then 
becomes necessary. Above all, fluid food should be avoided, as 
such a diet will make the patient's condition almost unbearable. 
Very many practitioners are afraid to give so-called gas-forming 
remedies, but these are often indicated. In the same manner that 
the sense of pressure in the epigastrium must be relieved by the 
taking of bicarbonate of soda, so we can often, by means of a diet 
rich in gas-forming foods, make it easier for the patient to expel 
gas from his bowel. Many patients of mine who are very sceptical 
on this point have, to their great surprise, been benefitted by this 
kind of a diet. But even in these cases individual predisposition 
must be taken into consideration. 

6. Diet in Diseases of the Rectum 

Not all affections of the rectum require a special regulation of 
the diet. Thus, no special diet is necessary in fistulse, ulcers, or 
foreign bodies in the rectum. This statement does not mean that 
in none of the affections of the rectum — especially the surgical dis- 
eases — is a regulation of the diet necessary. In some affections of 
the rectum — stenosis and strictures, hemorrhoids, and fissures — a 
systematic regulation of the diet is indicated. As regards the first 
of these affections, the diet to be ordered is the same as that for 
obstructions of the intestines situated higher up in the alimentary 
canal. 

Special treatment is necessary for hemorrhoids because of the 
tendency to constipation, alternating perhaps with diarrhoea, and on 
account of the bleeding which may occur. The bowels should be 



THE DIETETIC TREATMENT OP INTESTINAL DISEASES 157 

regulated, and for this purpose the " constipation diet" will usu- 
ally suffice. Where both patient and physician are impatient, mild 
laxatives may be used. 

Where the tendency to profuse hemorrhages exists, substances 
which increase the discharge of fluids from the intestines — i. e., 
acids, alcohol, spices — should, if conditions permit, be excluded from 
the diet. 

The diet in fissures of the rectum and proctitis should be so 
arranged that the movements are retarded as much as possible ; if 
necessary, opium may be used. Generally this treatment is very 
satisfactory to the patients because every movement is apt to be 
followed by severe pain. I keep these cases on a soup diet from 
eight to ten days. When the fissure has healed and there is no more 
pain during or after movements, a dose of castor oil should be given. 
Gradually the patient may be permitted to return to his usual diet. 
In proctitis the diet should be managed in such a manner that all 
irritating substances are excluded, and that the movements are soft 
and easily passed. When the movements are very painful the patient 
should be placed on a bland diet, and, until the inflammation has dis- 
appeared, the intestinal peristalsis should be diminished by means of 
opiates. Similar treatment is also called for in periproctitis, and is 
rendered more easy of accomplishment because the appetite of the 
patient is diminished through the severe pain and the high fever 
characteristic of the affection. In other cases, a careful empty- 
ing of the colon (by means of injections and intestinal lavage) is 
indicated. 

LITERATURE 

1. Rubner. Zeitschr. f. Biologie, Bd. xv, S. 115. 

2. Fr. Mtiller. Zeitschr. f. klin. Medicin, Bd. xii. 

3. Hirschler. Zeitschr. f. physiol. Chemie, Bd. x, S. 306. 

4. Ortweiler. Mittheilungen aus d. medicin. Klinik in "Wurzburg, 1886, 

Bd. ii. 

5. Bokai. Arch. f. experira. Pathol, u. Pharmakol., Bd. xxiii. 

6. Strauss. Zeitschr. f. klin. Medicin, Bd. xxix, 1896, S. 221. 

7. Gans. Berliner klin. Wochenschr. , 1889, No. 13. 

8. Sahli. Verhandl. des Congresses f. innere Medicin, 1895. 

9. Quincke. Ibid. 

10. Penzoldt. Handbuch d. spec. Therapie innerer Krankheiten. Bd. iv, S. 724. 



CHAPTEK IX 
THE HYDROTHERAPEUTIC S OF INTESTINAL DISEASES 

In the treatment of affections of the intestines, hydrotherapy 
plays almost as important a part as in that of the stomach. It is, 
however, very difficult to give a good account of the action of hydro - 
therapeutic measures, be the water taken internally or as baths, or 
both together, or to determine exactly what effects climatic influ- 
ences have upon the patient. The number of factors that have to 
be taken into account is so large that in the greater number of cases 
it is hard to say what part of the results obtained is due to rest and 
exercise, to diet, to the change in surroundings, or to the treatment of 
the physicians at the watering place visited by the patient. We are 
often in the position of the physician who has given a prescription 
containing four or five drugs ; the patient is improved, but the physi- 
sician is unable to say to which one of the drugs the result was due. 

The employment of mineral waters is to a certain extent empiri- 
cal, for we really have little positive knowledge concerning the action 
of these waters on the healthy or diseased intestines that we could 
use as a basis for a systematic treatment. Every busy practitioner, 
therefore, is accustomed to formulate therapeutic principles for him- 
self according to his experience with these agents. As in my Dis- 
eases of the Stomach, I shall also here give an account of the impres- 
sions which I have gained from an experience with a large number 
of carefully observed cases. 

For simplicity, hydrotherapeutic measures may be divided into 
the drinking of waters, hydrotherapeutic baths, seashore, and moun- 
tain-air cures. The hydrotherapeutic baths will be considered in 
the Special Part of this book. 

1. The Drinking of Waters. — The influence of a course of waters 
is based upon their action upon the intestine. They may stimulate 
or diminish peristalsis ; they may, so to say, wash out the entire 
alimentary canal and remove mucus, bacteria, and various toxic 
products from its interior. The waters may have only an indirect 
action upon the intestines ; for example, in those cases where an 
improvement of an affection of other organs (gastric, hepatic, or 
158 



THE HYDROTHERAPEUTICS OF INTESTINAL DISEASES 159 

cardiac disease) is followed by an improved condition of the intes- 
tinal functions. 

We will limit ourselves to a consideration of the direct action of 
waters upon intestinal diseases, and shall first give an account of the 
mineral waters which increase peristaltic action. These are : 

(a) Alkaline carbonated waters (main constituents, bicarbonate 
of soda and carbonic acid). 

(h) Alkaline muriated-carbonated waters (main constituents, so- 
dium carbonate and chlorid, carbonic-acid gas). 

(c) Sodium sulphate waters (main constituent, sodium sulphate). 

(d) Muriated waters (main constituent, sodium chlorid). 

(e) Bitter waters (main constituents, sodium and magnesium 

sulphate). 

As regards the first group, they have only a very slight effect in 
increasing the activity of the intestines. Owing to the sodium bicar- 
bonate and carbonic acid contained in them, they may act as laxa- 
tives when given in very large doses. Their use would be limited 
to very mild cases of constipation, and to those diseases in which a 
very slight laxative action is desired in addition to the general tonic 
effect of a mineral water. It need hardly be mentioned that the 
cold waters have more effect than the warm waters. 

Cold alkaline carbonated waters may be arranged, according to 
their percentage of bicarbonate of soda, into * Yals, Bilin, Fachingen, 
Fellathalquelle, Preblau, Salzbrunn, Geilnau, and (xiesshubl. Ther- 
mal alkaline carbonated waters are Yichy and ISTeuenahr. 

[In the United States we have the following springs of this 
class (arranged in the order of their percentage of bicarbonate of 
soda) : Cold springs : The California Seltzers, Azula Springs (Cali- 
fornia), Bladon Springs (Alabama), Adam's Springs (California), 
and Waukesha (Wisconsin). Thermal springs : Ukiah Yichy (Cali- 
fornia), Howard (Excelsior Spring) (California); and, as an example 
of the hot alkaline carbonated, we have Skagg's Hot Springs in 
California (temperature = 120° to 140° F.). ] 

The second group of waters, the alkaline muriated, have a similar 
action to that of the first group, except that the high percentage 
of sodium chlorid which some of them contain may make them par- 
ticularly useful in the treatment of constipation. Of course the 

* The detailed account of these mineral waters may be found in my work on 
the Diagnosis and Treatment of Diseases of the Stomach (Part I, p. 282 et seq., 
fourth edition). 



160 DISEASES OF THE INTESTINES 

temperature of the water lias its due influence. Among the cold 
muriated springs I may mention Sczawnicza (Magdalen Spring, 
4.61 grams of NaCl per litre), Luhatschowitz (Yincenz Spring, 3 
grams !NaCl per litre), Gleichenberg (Constantin Spring, 1.85 grams 
isTaCl per litre), Selters (2.3 grams NaCl per litre), Tonnistein (1.4 
grams per litre). Among thermal muriated waters may be men- 
tioned Ems (Fursten Springs, 1 gram NaCl per litre). 

[The most celebrated springs of this group in the United States 
are those of Saratoga in New York. In all, there are between 
twenty and thirty springs at this famous watering place. The amount 
of sodium chlorid found in them ranges from 1.86 grams (Flat 
Rock Spring) to 12.04 grams (Champion Spouting Spring) per 
litre. * Between these two extremes there exists a most varying 
percentage. Other cold alkaline muriated-carbonated waters are 
those of the Tolenas Springs, California (3.3 grams per litre) ; the 
Pacific Congress, California (2 grams) ; the Dixie Springs, Tennessee 
(1.9 grams) ; the St. Clair (Salutaris) Springs, Michigan, the Litton 
Seltzer, California (each containing about 1.4 grams to the litre) ; 
the ^Etna Soda Springs, California (0.5 gram to the litre) ; Mani- 
tou, Colorado (0.41 gram) ; the Medical Lake, Washington State, 
and the Plymouth Pock, Michigan (each with about 0.26 gram) ; 
and the Cresson Magnesia Springs, Pennsylvania, which contains 
but 0.021 gram to the litre. As examples of thermal and hot 
springs of the group under discussion we have the Las Yegas Hot 
Springs of New Mexico (temperature from 110° to 140° F.), whose 
largest spring (No. 6) contains 0.26 gram of NaCl to the litre ; 
the Ojo Caliente Hot Springs (temperature 90° to 122° F.), fifteen 
in number, and containing 0.38 gram to the litre ; the Aguas Cali- 
ente (Coahuila Yalley, California), which contain 0.53 gram to the 
litre, and whose temperature varies from 58° to 142° F. Finally, 
there is the Fountain Geyser of the Yellowstone National Park 
(temperature 179.6° F.), whose water is estimated to contain 0.54 
gram of NaCl to the litre, f] 

The third group of waters contains a greater or less quantity 
of sodium sidphate and a small percentage of sodium bicarbonate 
and chlorid, and carbonic acid. Cold water springs are Marienbad, 

[* These figures and most of those herein stated are taken from the tables of 
analyses given in Crook's Mineral Waters of the United States, etc., the latest and 
undoubtedly the best work on the subject. — Tr.] 

[f The waters of these hot springs are employed mostly for bathing pur- 
poses. — Tr.] 



THE HYDROTHERAPEUTICS OF INTESTINAL DISEASES 161 

Tarasp, Elster (Salt Spring), Rohitsch, Franzensbad (Salt Spring). 
Thermal springs are Carlsbad and Bertrich. 

The cold sodium sulphate waters have a greater cathartic action 
than the warm ones. Carlsbad is vaunted for its special good effects 
on chronic catarrhs of the small and large intestines. Marienbad 
and the Salt Springs of Franzensbad and Elster are particularly rec- 
ommended for hemorrhoidal affections and abdominal plethora with 
constipation. 

[Very few of the cold springs of the United States of which we 
have a trustworthy analysis contain a preponderance of sodium sul- 
phate over the other mineral ingredients. Such are the Lineville 
Mineral Springs of Iowa, which contain 3.1 grams of sodium sul- 
phate to the litre ; the Rocky Mountain Springs of Colorado, with 
1.8 grams of sodium sulphate to the litre ; the Aqua de Yida of 
California, the Lower Spring with 0.25 gram, and the Upper with 
0.3 gram to the litre. The Upper Spring also contains magnesium 
sulphate. Porter Springs, Colorado, contain 0.47 gram of sodium 
sulphate to the litre. 

The thermal and hot springs are more numerous. As examples 
we have the Arrow Head, the San Bernardino, and the Great Pa- 
raiso Hot Soda Spring of California ; the Pagosa and the Middle 
Park Hot Springs of Colorado ; the Ferris of Montana ; and Wal- 
ley's Hot Springs and Gibson's Mineral Well of Texas. The sodium 
sulphate in these waters varies from 0.021 gram (Walley's) to 4.4 
grams (Gibson's) to the litre.] 

The muriated waters contain more or less sodium chlorid and a 
considerable quantity of carbonic acid. Cold springs are Nauheim 
(Kurbrunnen), Neuhaus (Bonifacius Spring), Homburg (Elizabeth 
Spring), Mergentheim, Kissingen, Soden. Thermal springs are 
Wiesbaden (Kochbrunnen) and Bourbon les Bains. 

[Many cold waters of this group are found in the United States ; 
some have too high a percentage of sodium chlorid to render them 
suitable for anything but bathing. Such are the Neptune Spring 
(Glen Springs, New York), which contains 109.18 grams, and Clark's 
Red Cross Mineral Well (Michigan), containing 223.81 grams per 
litre. The best known of the drinking waters are those of Ballston 
Spa in New York (United States = 7.29 grams sodium chlorid and 
Sans Souci — 1.46 grams to the litre) ; Sheboygan Mineral Well in 
Michigan, with 5.24 grams ; and Glen Springs in New York (Salu- 
bria = 3.37 grams ; Deer Lick = 1.99 grams). Less generally 
known, but enjoying an excellent local reputation, are the Louis- 



162 DISEASES OF THE INTESTINES 

viile Artesian Well (Kentucky), the Lodi Artesian Well (Indiana), 
the Sweet Springs of Missouri, the Spring Lake Well of Michigan, 
the Wasatka Mineral Springs of Utah, and the Coronado Springs 
of California. A number of otherwise excellent muriated waters 
contain large amounts of sulphuretted hydrogen, so that, strictly 
speaking, they do not belong in this class. These include the 
Upper and Lower Blue Lick and the Olympian Springs of Ken- 
tucky, the Akesion (Sweet Springs) of Missouri, the Cincinnati 
Sulpho-saline Spring, etc. 

There are fewer hot and apparently no thermal muriated springs. 
The Utah Hot Springs (131° to 140° F.), the Yampa (Glenwood 
Springs (Colorado) (124.2° F.), and the Royal Gorge Hot Springs 
(Colorado) (102° F.), used for bathing purposes, are to be classed with 
this group of waters.] The muriated waters improve the appetite, 
and in large doses increase intestinal peristalsis and thus clear the 
organism of excrementitious material. [They are contraindicated in 
intestinal conditions accompanied by diarrhoea, as well as in affec- 
tions of the stomach associated with increased acidity.] The main 
action of the bitter ivaters is cathartic, and hence they may be used 
to clear the blood and general system of useless substances. We may 
mention Franz Joseph Spring in Buda-Pesth (24 grams of magnesium 
sulphate and 23 of sodium sulphate per litre), Hunyadi Janos in 
Buda-Pesth (16 grams of magnesium sulphate and 15 of sodium sul- 
phate per litre), Puma in Bohemia (12 grams of magnesium sulphate 
and 16 of sodium sulphate per litre), Friedrichshall (5 grams of 
magnesium sulphate and 6 of sodium sulphate per litre), Apenta, etc. 

[There are between twenty and thirty cold and thermal bitter- 
water springs in the United States. Although none have as high a 
percentage of magnesium or sodium sulphate as the above-mentioned 
European waters, still many of them are excellent cathartic waters. 
At the head of the cold springs stand the B. B. Mineral Springs of 
Missouri, which contain 11.5 grams of magnesium sulphate and 1.04 
of sodium sulphate per litre; the Estill (Purgative) Springs, 4.5 
grams of magnesium and 1 of sodium sulphate ; the Epsom Spring 
(Crab Orchard, Kentucky), 3.5 grams of magnesium and 1 of 
sodium sulphate per litre ; the Harrodsburg Springs, Kentucky 
(Saloon Spring = 3.8 grams and Grenville = 2.2 grams magnesium 
sulphate per litre) ; Sowder's Spring (Crab Orchard) has 3 grams 
of magnesium and 0.4 of sodium sulphate ; Foley's Spring, 3.4 
grams of magnesium and 1 of sodium sulphate ; Mono Lake (Cali- 
fornia) contains 2.1 grams of magnesium and 0.3 of sodium sul- 



THE HYDROTHERAPEUTICS OF INTESTINAL DISEASES 163 

pliate ; the American Carlsbad Springs * (Illinois), 1.8 grams of 
magnesium and 0.1 of sodium sulphate, and the Gypsum Springs 
of Arizona have 1.7 grams of magnesium with 0.5 of sodium sul- 
phate. The remaining springs contain magnesium sulphate in 
amounts varying from 0.02 gram to 0.9 gram to the litre. Men- 
tioned according to their percentage of magnesium sulphate, they 
are the Alleghany Springs of Virginia, the Mineral Park Bitter 
Spring (Arizona), the Greenbrier (West Virginia), the Bedford 
(Magnesia and Bowling Alley) Springs (Pennsylvania), Seigler's 
(Magnesia) Spring (California), and the Mount vale Springs (Ten- 
nessee). Others charged, however, with sulphuretted hydrogen 
are the Avon Sulphur and Sharon Springs f of New York, the Salt 
Sulphur Springs of West Virginia, the French Lick Springs (Pros- 
erpine and Pluto) of Indiana, and the Indian Springs of Georgia. 

As examples of thermal and hot bitter waters we cite the Soda 
(drinking) Spring (Virginia Hot Springs), temperature = 74° F. ; 
the Idaho Hot Spring (Colorado), temperature = 85° to 115° F. ; 
the numerous Catoosa Springs of Georgia, temperature = 212° F.] 

There are some mineral waters which diminish peristalsis. All 
the waters mentioned above, except the bitter waters, when they are 
taken warm and in small doses, have this action. Especial mention 
must be made of Carlsbad Sprudel water, which has a great reputa- 
tion in chronic diarrhoea. In addition, the waters which contain 
lime and iron must be considered in this connection. 

Of the lime waters, particularly those which contain calcium 
carbonate, Germany has the following varieties : Wildungen (Konig's 
Spring), Driburg (Herster Spring), Lippspringe (Arminius Spring), 
Pappoldsweiler (Carola Spring), Marienbad (Rudolf's Spring), Co- 
burg (Mariannen Spring) ; the last-named water is generally used for 
exportation. The table below gives the composition of these waters : 



Wildungen (Konig's Spring, temperature 10° C). . . 
Driburg (Herster Spring, temperature 10.6° C.) . . . 
Rappoldsweiler (Carola Spring, temperature 18° C.) 
Lippspringe (Arminius Spring, temperature 21 . 2 C.) 
Coburg (Mariannen Spring) 



Carbonate of lime 


Free CO a . 


and carbonate of 


Cubic 


magnesium in litres. 


Centimetres. 


2.23 


1,322 


1.51 


1,043 


0.77 




0.61 


646 


0.3463 


343 



[* The name " Carlsbad " is inappropriate, for the waters of Carlsbad in Bohe- 
mia contain large quantities of sodium sulphate, and no magnesium sulphate 
whatever.] 

[f This is essentially a sulphuretted hydrogen and sulphate of calcium spring.] 



164 DISEASES OF THE INTESTINES 

[The list of carbonate of calcium S23rings in the United States is 
too long to be even detailed here. A number of them contain 
considerable quantities of this salt. All the Saratoga waters have 
it in amounts ranging from 0.72 gram to the litre (Empire and 
Eureka Springs) to 2.9 grams (Geyser Spouting and Hathorn) and 
3.9 (Champion Spouting). * Other waters of this class are the 
Americanus Mineral Well (formerly Michigan Congress), with 1.47 
grams per litre ; California Seltzer, with 1.25 gram ; Montesano 
(Missouri), 1.2 grams; Tolenas (California), 0.85 gram; Sans 
Souci Springs (Ballston Spa, N. Y.), 0.74 gram ; Akesion (Sweet 
Springs, Mo.), 0.69 gram ; and the Soda (Summit Springs, Cal.), 
0.65 gram to the litre. To mention a few others with lesser 
amounts of calcium carbonate, there are the Geneva Lithia, the 
Adirondack, and the Avon Sulphur (Lower) Springs of New York ; 
the Kickapoo and Indian Springs of Indiana ; the Sheboygan and 
Leslie of Michigan ; the Boiler (bathing) and Soda (drinking) of 
Virginia Hot Springs ; the Royal George of Colorado, Waconda of 
Kansas, Crocker of Tennessee, Old Sweet of West Virginia, the 
Upper and Lower Blue Lick of Kentucky, the Bartlett of Cali- 
fornia, etc.] 

The Iron or Chalybeate Waters. — These contain carbonates as 
well as sulphate of iron, and have a tendency to diminish secretion 
in the body. They are especially useful in chronic diarrhoea or 
intestinal catarrhs with diarrhoea, of which anaemia is the causative 
factor. The best known carbonated chalybeate waters are Franzens- 
bad, Elster, Driburg, Reinerz, Kippoldsau, Pyrmont, Schwalbach, 
and Cudowa. Of sulphate-of-iron waters we may mention Konneby 
in Sweden, Levico and Boncegno waters, and the Guber Spring. 

[Many waters of this country have been found upon analysis to 
be very good chalybeates. Combining, as many of them do, a 
goodly proportion of other minerals (sodium, magnesium and cal- 
cium, chlorids, carbonates, and sulphates), they are seen to be most 
excellent mineral waters. But a limited number can be mentioned ; 
an analysis and other details will be found in works devoted to the 
subject of mineral waters (Crook, A. N. Bell 2 , Walton 3 , etc.). 
Named in the order of their percentage of carbonate of iron, we 
have the Iowa White Sulphur Springs ; the Chittenango Sulphur 
Springs of New York (Magnesia Spring) ; the Owasso Spring 

[* In addition to the amount of calcium carbonate here stated, the Saratoga, as 
well as all the other waters of this class, contain considerable proportions of mag- 
nesium carbonate. — Tr.1 



THE HYDROTHEKAPEUTICS OF INTESTINAL DISEASES 165 

(Michigan) ; the Pacific Congress (California) ; the Sparta Mineral 
Wells, Wisconsin (Magnetic Mineral Well) ; Napa Soda Springs 
and Mono Lake of California ; Fruit Port Well (Michigan) ; Sara- 
toga Springs, New York (Putnam, Columbia, Hamilton, Excelsior, 
and Eureka Springs) ; Wilhoit's Soda Springs (Oregon) ; Ballston 
Spa (Sans Souci) and the Adirondack Spring of New York ; 
Arrington Springs (Nos. 1 and 2), Kansas; Americanus Mineral 
Well (Michigan) ; Massanetta Springs (Virginia), etc. 

The following are the principal waters containing the sulphate 
of iron ; they are arranged according to amount of that salt found 
in them : The Overall Mineral Wells (Nos. 2 and 1) of Texas ; the 
Oak Orchard Acid Springs (No. 2) of New York ; Gaylord and 
Garlick's Mineral Springs of Pennsylvania ; Bath Alum Springs (No. 
2) of Yirginia ; Indian Springs (Indiana) ; Bedford Alum Springs 
(Virginia) ; Texas Sour (or Caldwell's) Springs ; Austin's Springs 
(Tennessee) ; Iron Lithia Springs (Yirginia) ; Wilbur's Springs 
(California) ; Fauquier's White Sulphur Springs (Yirginia), etc. 
In addition, sulphate of iron has been found in a number of the 
California geysers in amounts ranging as high as 0.49 gram to the 
litre. 

Free sulphuric acid is found in the Oak Orchard Springs (about 
2.25 grams per litre) ; the Texas Sour Springs (0.124 gram per 
litre) ; the G-aylord and Garlick, the Iron Lithia, and Bath Alum 
Springs (about 0.086 gram per litre) ; the Bedford Alum (about 
0.068 gram per litre) ; and owing to its acid reaction is probably 
also present in the Overall Mineral Wells (Crook).] 

In some cases — I believe in far too few — enemata of mineral 
water are made use of. For this purpose the thermal waters of 
Carlsbad, Ems, Wiesbaden, and Neuenahr are especially appro- 
priate, particularly if there exist a catarrhal affection of the lower 
segments of the intestines. Pollatschek x , more than any one else, 
has reported very favourable results from small enemata (100 to 
200 cubic centimetres) of warm mineral waters in chronic catarrh 
of the large intestine and in ulcerative processes and intestinal neu- 
roses. I should think that small quantities of chalybeate waters per 
rectum might be useful in these cases in which iron is not well 
borne by the stomach. 

If, after this brief resume, we next ask ourselves what practical 
benefits are to be derived from the use of the above-named mineral 
waters, we shall find it very difficult to answer our question satis- 
factorily. 
12 



166 DISEASES OF THE INTESTINES 

As already mentioned, so many subsidiary factors are to be 
taken into account that it is difficult, if not impossible, to clearly 
define their individual action. Notwithstanding this, the following 
statements are probably correct. To simplify matters let us classify 
the most frequent intestinal affections as chronic catarrhs of the 
large and small intestines, chronic constipation, and chronic diar- 
rhoea. It would be correct also to distinguish between mild and 
severe types, but such a division depends largely upon subjective 
impressions. 

In the milder catarrhs of the small intestine I have seen excellent 
permanent as well as temporary results from the thermal waters of 
Carlsbad. These cases are unsuitable for the cold sodium sulphate, 
the muriated, or the carbonated springs. The warm Carlsbad 
waters are also most beneficial in mild catarrhs of the large intes- 
tine, associated with constipation or with constipation alternating 
with diarrhoea. Next to these waters, the cold sodium sulphate and 
the warm and cold muriated waters give the best results. Good 
results are sometimes obtained from the waters of Ems. 

Positive benefit may be expected in hemorrhoids from the use 
of the Glauber salt waters (particularly Marienbad), as well as from 
the cold muriated waters (especially Kissingen, Homburg, and Mer- 
gentheim). The effect is frequently permanent ; usually, however, 
the course of waters must be repeated. Water treatment in mild 
cases of habitual constipation is fairly satisfactory. These are 
sometimes permanently relieved by the sodium sulphate and muri- 
ated waters, but generally the relief is only temporary. 

Improvement may be expected in chronic diarrhoea from the 
use of the Carlsbad waters (the Sprudel in small amounts), the 
muriated waters (small doses warmed), and from the waters of Ems. 

The above-mentioned calcareous waters are very useful in 
chronic diarrhoea, although, strange to say, they are very little used 
for this purpose. In combination with a suitable diet I obtain 
good results from their use. From an extended personal experi- 
ence I can warmly recommend the Marienbad Rudolfsquelle, the 
Coburg Mariannenquelle, and the Lippspringer Arminiusquelle. 

Severe forms of intestinal catarrh, constipation, and diarrhoea 
are less likely to be benefitted by a course of mineral waters. The 
results are either temporary or entirely negative. Of the many 
hundreds of private patients who have drunk the sulphated or the 
muriated waters at the original springs, I have not yet seen one 
who has derived any permanent benefit from the waters themselves. 



THE HYDROTHERAPEUTICS OP INTESTINAL DISEASES 167 

I could note an improvement only in those patients who had other 
treatment, and for whom, therefore, the drinking of the waters 
was really superfluous. 

The cause of failure in these cases is very clear. Proper regu- 
lation of the diet is the main factor in the treatment of the severer 
types, and not even in a place so well organized as Carlsbad is this 
feature as thoroughly attended to as is necessary. Rest in bed for 
a longer or shorter period is essential to the cure of the severer 
forms of chronic diarrhcea and of the intestinal catarrhs that cause 
them. It is very difficult or even impossible to obtain this in a 
watering place, unless the latter contains a sanitarium such as have 
of late been successfully introduced in various watering places. 
From this it follows that only mild and very recent cases are 
adapted to a course of water treatment ; all others should be 
treated in a sanitarium or a hospital. Since a number of mineral 
watering places (e. g., Kissingen, Wiesbaden, Carlsbad, Baden- 
Baden, etc.) have now well-conducted private institutions in which 
proper regulation of the diet can be, wherever necessary, combined 
with mechanical therapeutic measures such as massage, intestinal 
irrigations, etc., we can now send even severe and protracted cases 
away. There are, more such private sanitaria throughout Germany 
and Switzerland, but as it is impossible to commend them all in 
this place we refrain from mentioning any.* 

Is the benefit to be derived in mild cases sufficient to warrant a 
patient in moderate circumstances incurring the heavy expenses of 
such a cure ? Where a permanent cure can not be anticipated— and 
this is true in the majority of cases — it is best to advise against such 
treatment. With the wealthier classes it is quite different, for they 
visit the baths every year, either from custom or in order to recu- 
perate from the trials of winter society. It matters, therefore, very 
little to them whether they derive any benefit from the course of 
waters or not. At all events, it is wrong to promise any patient a 
permanent cure of his intestinal trouble from a four weeks' course 
at a mineral spring. Unfortunately, the physician is too optimistic 
regarding the effects of mineral waters, and it is not surprising, 
therefore, that failure to obtain such results is explained upon the 
ground that " the wrong spring was selected." 

Mineral waters are often drunk at the home of the patient. This 

* A fairly complete list will be found in Penzoldt-Stintzing's Handbuch d. spe- 
ciellen Therapie innerer Krankheiten, 1. Aun., Bd. iv, S. 274. 



158 DISEASES OF THE INTESTINES 

is advisable, if at the same time it can be combined with proper 
dieting and also a certain amount of rest and freedom from daily 
occupation. It is also useful as a preliminary test in doubtful cases. 

2. Baths. — Yery often baths are given in connection with a 
course of mineral waters and may even constitute the main part of 
the treatment. They are classed as natural baths, iron, salt-water, and 
mud [" moor "] baths. The last-mentioned variety are very impor- 
tant in the treatment of chronic exudative processes about the intes- 
tines. The mud baths of Marienbad, Franzensbad, and Elster are 
the most popular ones.* Salt-water baths are found inland in low as 
well as in mountainous regions (Reichenhall, Kosen, Salzungen, etc.) 
and at the seashore (Colberg, Swinenxiinde, etc.). There can be no 
doubt as to the favourable influence of these baths upon many cases. 
Thus in perityphlitic exudations I have occasionally observed re- 
markable benefit follow the use of salt-water baths. For a com- 
bination course of mineral waters with salt-water bathing Kissingen 
and "Wiesbaden are good ; for a course of waters with mud baths, 
Marienbad, Elster, Franzensbad, and Pyrmont are best. 

3. Climatological Treatment (Seashore and Mountain Air). — 
This may be recommended alone, or may also be combined with a 
course of mineral waters. Without doubt climatic treatment is best 
adapted to nervous affections of the intestines. It is very often also, 
and quite correctly, advised as an after treatment to a course of 
waters. The physician will very frequently have to decide for his 
patient between seashore and mountain air. This question can 
only be considered for the individual case ; very frequently, indeed, 
equally valuable results may be obtained from either region. As a 
rule, patients whose ordinary vocation inclines them to sedentary 
habits should be sent to the mountains ; while those living in large 
inland cities and accustomed to excitement and running about, and 
to gross irregularities in eating and drinking, should be sent to the 
seashore. On the other hand, those suffering from organic intesti- 
nal disorders should not be sent to the seashore or to the moun- 
tains. I would warn against permitting patients suffering from 
chronic intestinal catarrhs to partake of table cPhote meals such as 
are ordinarily served at the seashore or in the mountains. As al- 
ready mentioned, it is often possible to combine cold-water treat- 

[* In the United States mud baths are given, among other places, at the 
Arkansas, Virginia, and Las Vegas Hot Springs. At these resorts elaborate bath- 
ing establishments, modelled after those in vogue at the most celebrated European 
watering places, have been established. — Tr.] 



THE HYDROTHERAPEUTICS OF INTESTINAL DISEASES 169 

ment with, a sojourn in the mountains, and in suitable cases we 
ought to take advantage of this. Owing to the enormous number 
of seaside and mountain resorts in Germany and in foreign coun- 
tries, it is impossible to give even a partial list of them. 



LITERATURE 

1. Pollatschek. Wiener med. Wochenschr. , 1891, No. 23. 

[2. A. N. Bell. Climatology and Mineral Waters of the United States, New 

York, 1885.] 
[3. Walton. Mineral Springs of the United States and Canada, 1872.] 



CHAPTEK X 

MASSAGE. ELECTRO-THERAPEUTICS AND HYDRIATRICS IN 
INTESTINAL DISEASES 

1. Massage 

In intestinal diseases massage is employed to stimulate the re- 
laxed muscles of these organs, and to cause diffusion and absorption 
of local inflammatory and peritoneal processes. 

The most frequent indication for massage is furnished by atony 
of the intestines. 

Technic of Intestinal Massage* 

In order to relax the abdominal walls we begin with rotary 
effleurage (stroking). In stout persons this is followed by petris- 
sage (kneading), the object being the crushing of individual fat 
globules. Petrissage of the deeper tissues is the most important 
manipulation in intestinal massage. 

" With both hands we grasp the intestines through the abdominal 
walls, and as though we were handling a muscle that we wished to ex- 
press, we make the same zigzag forward and backward movements 
that we would in kneading such muscle. We thus proceed over the 
entire abdomen. The next step is to stroke the fsecal masses out of 
the intestines. We begin with the ascending colon, pass upward, 
follow to the left along the transverse colon, and then continue 
downward until we reach the sigmoid flexure. At first, stroking 
movements are made ; later, rotary petrissage is substituted, for this 
acts more energetically in mechanically removing faecal contents." 
Hoffa describes " rotary petrissage " (kneading) as follows : " With 
the hands held at an acute angle to the abdominal wall, and with 
the finger tips of the left hand resting upon those of the right and 

* We here follow the description given by Hoffa in his Technik der Massage 
(Stuttgart, 1893), to which work the reader is referred for all further details. (Com- 
pare also the section on Massage in my Diagnostik und Therapie der Magenkrank- 
heiten, Part I, p. 324, fourth edition.) 
170 



MASSAGE 



m 



directed upward toward the chest, rotary movements are made in 
the ileo-csecal region [Fig. 22]. Since sudden pressure would result 
in rigidity of the abdominal walls, the rotary movements must be 
gentle, the deeper parts being very gradually approached. The 
movement is the same that we make in palpating deep-seated ab- 
dominal tumours. The patient is told to breathe deeply, and with 




[Fig. 22. — Position of Hands and Direction of Movements in 
Intestinal Massage (Hoffa). — Tr.] 

each expiration we press deeper. The advancing movement on the 
part of the operator proceeds directly from the shoulder joint, while 
the finger, wrist, and elbow joints should be held almost rigid." 

Tapotement {percussion) and vibrations of the abdominal wall 
follow the deep petrissage. These tend to stimulate the smooth 
muscles of the intestines, and to promote alterations in the circula- 
tion in the blood-vessels. 

Besides atony of the intestines (especially that associated with 
flatulence), massage is beneficial in localized peritonitic processes 
about the intestines, particularly in perityphlitis or appendicitis after 
the acute stage has passed. In these cases the greatest care must be 
taken. Above all, we should make it a strict rule never to begin 
massage until weeks after all inflammatory manifestations have dis- 
appeared. The regions of the caecum must no longer be sensitive 
to pressure. It is hardly necessary to state that if there is the least 
suspicion of an abscess or of tubercular appendicitis massage should 
never be attempted. 

This last precaution applies also to new growths of the intestinal 



172 DISEASES OF THE INTESTINES 

tract, benign as well as malignant. I would also warn against 
employing massage in intestinal obstruction. As a rule, it can only 
add to the gravity of the condition. 

Each sitting should last ten minutes, and no single manipulation 
should require more than two or three minutes. The treatment 
should first be conducted daily for four weeks ; after that every 
two or three days for four to six weeks. In constipation the results 
from massage will vary largely, for they depend upon the degree of 
the intestinal difficulty, as well as upon the patience of the subject, 
and above all upon the skill of the masseur. My own experiences 
in the matter have led me to form the following conclusions : A 
permanent result (i. e., regular and sufficient intestinal evacuations) 
can be obtained from properly conducted massage combined with 
therapeutic measures which tend to bring about the same result — 
i. e., diet, gymnastics, electricity, rowing, turning, and other bodily 
exercises. 

On the other hand, in some cases of intestinal atony I doubt very 
much whether massage alone can give more than temporary relief. 
Yery soon after the discontinuance of the massage, even though 
applied for weeks by an experienced person, the intestine usually 
fails to properly perform its functions. This result is quite con- 
trary to that obtained from the above-mentioned diet (page 000), 
where in the vast majority of cases a permanent effect is secured, 
continuing even when the diet regime is no longer strictly followed. 
We do not deny that exceptions do occur, but these do not alter the 
general rule. 

Regarding massage in localized peritonitis, I can say but very 
little, for my experience has not been extensive. I am, however, in 
favour of a trial under the above-mentioned precautions. At times 
considerable benefit may be derived from the combination of mas- 
sage with indoor gymnastics, such as have been introduced by Gr. 
Zander. This is not the place to enter into a description of such 
gymnastics, especially as they can only be learned through practical 
experience. 

2. Electrical Treatment 

This includes the use of the faradic, the galvanic, and the 
galvano-faradic (mixed) currents. The application, as in the stom- 
ach, may be either external or intra-abdominal, or, more correctly 
speaking, rectal. At present opinion is very much divided as to 
whether galvanism or faradism, or their combination, is more bene- 



ELECTRICAL TREATMENT 173 

ficial, and also as to whether the extra-abdominal or intrarectal 
method gives the best results. In fact, some authors regard the 
application of electricity to the intestines as utterly useless. 

Our scientific knowledge regarding the action of the electric 
current upon the intestines is very limited. We know that visible 
and palpable intestinal movements can be produced in persons with 
thin abdominal walls or with inguinal hernia (von Ziemssen). In a 
case of peristaltic restlessness under my observation we could detect 
a temporary increase of the intestinal peristalsis. The only sys- 
tematic experiments were those of Schillbach 1 upon exposed rab- 
bits' intestines kept in a bath of normal salt solution. His results 
would seem to indicate that the faradic and the galvanic currents 
differ in their effects upon intestinal peristalsis, inasmuch as a faradic 
current of medium strength causes — particularly in the small intes- 
tine and less so in the large — ascending and descending waves of 
contraction of a few centimetres of the stimulated bowel. With the 
galvanic current he observed localized contractions at the cathode, 
and peristaltic waves of contraction at the anode. In view of these 
observations, Leubuscher 2 and Schillbach particularly recommend 
the employment of intrarectal galvanization (anode on the abdom- 
inal wall, cathode in the rectum), and from their experience they 
believe galvanization gives better results than faradization. There 
is considerable discrepancy between the views of authorities on the 
efficiency of electro-therapeutic measures. Nothnagel 3 considers 
electrization of the intestine less beneficial than massage ; Ewald 4 , 
too, sees little or no use from electricity in intestinal diseases. On 
the other hand, Eichhorst 5 reports a case in which unsuccessful 
attempts were made for eight days to secure a movement of the 
bowels, and in which a single application of the faradic current was 
followed by copious evacuations and complete cure of the patient. 
Unfortunately, the nature of the obstruction (faecal impaction ?) can 
not be determined with certainty from the published reports of these 
cases. 

I should like to describe the technic of intestinal electrization 
before speaking of the results gained from my own experience. 
For external application either broad electrodes are to be employed 
or electric rollers or brushes. As in the electrical treatment of the 
stomach, so in intrarectal electrization, I have many years employed 
a soft-rubber tube, with numerous perforations near its tip and with 
a platinum spiral in its interior (Fig. 23). In addition to the switch 
for making and breaking the current, the upper part also is provided 



174 



DISEASES OF THE INTESTINES 



with a small tube for the in- and outflow of water. The filling of 
the rectum is accomplished in the usual manner by a funnel and 
rubber-tube attachment. From 100 to 200 cubic centimetres of 
lukewarm water are allowed to flow into the bowel. The other elec- 
trode is placed upon the abdomen and is moved along the entire 
course of the large intestine. Each application should last ten 
minutes. The faradic current can be applied strongly enough 
to produce distinct visible muscular contractions ; the patient 
should experience a definite and barely painful prickling sensa- 
tion. Twenty to thirty milliamperes of the galvanic current will 
suffice. 

My personal experience is limited almost entirely to intrarectal 
faradization. My conclusions are to be considered all the more 

trustworthy because I resort to intesti- 
nal electrization only when other means 
have failed (i. e., in the most obstinate 
cases), and I seldom combine different 
methods of treatment. I can state that 
intrarectal treatment succeeds in many 
of the cases in which nothing at all 
could be accomplished by massage, diet, 
or gym?iastics. The patients have well- 
formed movements daily. We can ex- 
clude any possible action from the water, 
for, aside from the fact that it is with- 
drawn through the tube at the termina- 
tion of each electrical application, those 
cases of constipation in which I employ 
intrarectal faradization are of such an 
obstinate nature that small enemata of water have no effect what- 
ever. Besides this, defecation does not immediately follow rectal 
faradization, but frequently occurs only after many hours. In 
some cases a permanent benefit is obtained, in others the patients 
are compelled for months to use the electric rectal sound. Aside 
from the so-called auto-massage, which is hardly deserving of seri- 
ous attention, electrization has the advantage over massage that any 
intelligent patient can employ it for months on himself. 

The use of the electric current is therefore generally indicated 
in paresis of the intestinal muscle ; its most important sphere, how- 
ever, lies in those forms of habitual constipation in which over-dis- 
tention of the ampulla recti had gradually led to paresis of the rectal 




Fig. 23. — Electeic Kectal Tube. 



HYDRIATRIC MEASURES 175 

muscles and sphincters. In this condition, skilfully applied elec- 
trical treatment will, as I have repeatedly convinced myself, result 
in permanent benefit to the patient. 

[Since the publication of this work, the translator has frequently 
been asked by American physicians where the Boas electrode, de- 
scribed on opposite page, can be purchased. Xot being able to 
furnish this information, he has had Stohlmann, Pfarre & Co., of 
this city, construct a special electrode for him. As can readily be 
seen from the illustration (Fig. 23a), the instrument consists of the 



STOHUCANH, PFARRE & CO. 

Fig. 23a. — Eectal Electrode (Basch). 

usual soft-rubber tube with perforations near the distal end, into 
which pass two long, narrow, parallel rubber tubes of unequal 
length. The shorter one is simply a catheter with the end clipped 
off, and serves for the in and out flow of water. The longer tube 
contains a metal spiral with a projecting metallic knob below, and 
a metallic key for connection with the electric apparatus above. A 
short hard-rubber stopper supports the two tubes and at the same 
time fixes them firmly in the outer perforated tubing. This stopper 
is very readily removed. The indications for its employment and 
technic are identical with the instrument described on the opposite 
page.] 

3. Hydriatric Measures 

In diseases of the intestines, use is made of external and in- 
ternal hydriatric measures. The internal ones are mostly limited to 
the use of water in the rectum, and owing to their great practical 
importance will be treated of separately elsewhere. In the follow- 
ing we will consider external hydrotherapeutics only. Of these we 
employ : 

1. Moist Applications. — These may be cold, warm, so-called 
" Priessnitz " (moist) applications and poultices. The former class 
exert a stimulating, the latter a sedative, action on the bowel. The 
Priessnitz pack while cold stimulates, and later exerts a sedative 
influence on the gut. Hot bran poultices relieve pain, probably 
owing to the fact that the heat causes a momentary paralysis of the 
sensitive nerve-endings. Hot or cold water bottles or water bags 



176 DISEASES OF THE INTESTINES 

may be used instead of moist applications : in general practice, clay 
bottles filled with hot water and wrapped in flannel or some such 
impermeable material suffice. In place of hot bran poultices, I 
have long used pieces of felt dipped in hot water and then covered 
with an impermeable material. 

2. Baths. — These are classed as full baths, half baths, and sitz 
baths, all of which can be given at varying temperatures and com- 
bined with other hydriatic measures. 

3. Douches. — These are given in the form of cold or warm or 
of alternating hot and cold (Scotch) douches. They are classed as 
shower, needle, jet, and vapour douches. 

4. Cold or Lukewarm Applications, with Friction, etc. — In most 
cases these different procedures are combined in various ways, and 
frequently electricity or massage is given in connection with them. 
It would be out of place to enter into a detailed description of these 
here. External hydrotherapeutic measures are mainly indicated in 
chronic and benign intestinal affections — i. e., catarrhs and neuroses. 
Intestinal neurasthenia in particular is often very much benefitted 
by hydriatic treatment. At the present day hydrotherapeutic treat- 
ment is applied almost exclusively in institutions, and its results are 
in part due to the water applications, but more so, in many cases, to 
the personality of the conductor of the institute. It can be readily 
understood that those institutions are best which provide an indi- 
vidualized diet regime. 

LITERATURE 

1. Schillbach. Virchow's Archiv, Bd. cix, 1887, S. 278. 

2. Leubuscher. Centralbl. f. klin. Medicin, 1887, No. 25. 

3. Nothnagel. Die Erkrankungen des Darms. Wien, 1895, S. 42. 

4. Ewald. Berliner Klinik, Heft 105, 1897. 

5. Eichhorst. Handbuch d. speciellen Pathologie u. Therapie, 4te Aufl.. 

1890, Bd. ii, S. 264. 



CHAPTEK XI 

INJECTIONS (ENEMA TA, INTESTINAL LAVAGE, AND DOUCHES), 
INFLATION, AND GASTRIC LAVAGE IN INTESTINAL DIS- 
EASES 

1. Injections (Enemata, Intestinal Lavage, and Douches) 

Injections are employed for various purposes : 

1. To stimulate peristaltic action, or by softening hardened faeces 
to facilitate their removal. 

2. As intestinal lavage, (a) for the removal of pathological sub- 
stances (mucus, blood, and pus); (b) for the purpose of irrigating 
the mucous membrane with watery solutions of medical substances. 

3. Mechanically to remove concrements and foreign bodies. 

4. As douches, to strengthen and stimulate the paretic intestinal 
muscle. 

Technic. — Nowadays enemata are given either by means of an 
irrigator consisting of a reservoir of varying material (rubber, glass, 
or metal) connected by rubber tubing, the so-called rectal tube ; or 
else by means of Hegar's apparatus, in which the reservoir is 
formed by a glass or rubber funnel. The irrigator is better adapted 
for use by the patient himself than is Hegar's apparatus, but the 
latter is far more preferable for the giving of an enema by a second 
person, since it permits him to regulate the pressure, and in case of 
too much distention, by simply lowering the funnel, to let any 
desired amount of water or air out of the intestine. For auto- 
irrigations I recommend an irrigator holding 3 litres, which is 
fastened to a support, and, like the well-known Leube-Rosenthal 
apparatus for gastric lavage, is also furnished with a T-shaped tube. 
According to Quincke, the rectal tube is best made of soft rubber ; 
the English [French] stiff or hard-rubber tubes are decidedly infe- 
rior to it, and if employed at all, should be thick and rounded off at 
their lower end and provided with two or three large [lateral] open- 
ings. To avoid injury to the parts, all rectal instruments should be 

177 



178 DISEASES OF THE INTESTINES 

smooth and free from cracks. For this reason soft-rubber tubes 
are to be preferred. 

In place of the above-mentioned apparatuses there are others 
adapted to auto -injections per rectum (e. g., the so-called injection 
pumps, alpha syringes, etc.), all based upon the principle of forcing 
water into the rectum under a certain degree of pressure. All in 
all, the value of these and similar apparatuses described in the cata- 
logue of instrument makers is not very great. Even their advantages 
for use during travel is questionable. I would emphasize, better re- 
sults are not obtained with these than with the irrigator or funnel. 
As regards the technic of giving or taking an enema, in the first place, 
one must have a definite idea of the object in view. If it be desired 
to act upon the colon in order to stimulate peristalsis, this is best 
done with the rectum as empty as possible. The method employed 
is similar to that used in giving an intestinal douche, to the discus- 
sion of which we refer the reader for technic and indications. 

For the removal of hardened faecal masses from the intestine, 
we employ thermal, mechanical, chemical, or electrical methods, 
singly or combined. 

Thermal stimuli consist in the injection of cold fluids of a tem- 
perature of 18° C. [65° F.] or less. Sometimes irrigations of ice 
water are recommended — e. g., in bleeding from hemorrhoids — but 
such measures are not without danger. 

The mechanical effect is obtained, in the first place, from the 
introduction of the instrument itself, and, secondly, from the in- 
jected water. 

The purpose of chemical agents is either to exert an influence 
upon the intestinal wall or to soften hardened faeces. 

The effect of intrarectal electrical treatment has already been 
described on page 174. 

It is not easy to state which of these methods is the best. In 
some cases — i. e., in certain stages of constipation — one apparently 
obtains good results from any one of them. Without doubt, indi- 
vidual idiosyncrasies play an important role here just as they do 
in the medicinal treatment of constipation. I shall not, therefore, 
enter into a discussion of the relative value of the various methods 
in use, but shall confine myself to those which my experience has 
taught me are best. 

The quantity of fluid that should be injected into the rectum is 
a question of primary importance. It is clear that 1 or 2 litres 
of fluid, when injected into the lower portion of the bowel, will 



INJECTIONS 179 

cause an acute extreme distention of the intestine and a resulting 
tenesmus, so that the greater part or the whole of the fluid is expelled 
without sufficient purgative action. It is immaterial whether one 
uses cold or warm water, oil, vinegar, soapsuds, or glycerin. Even 
the more active irritant remedies exert an insufficient influence 
upon the bowel when they remain in it for a short time only. If 
the lowermost portion of the intestines contain faecal masses, these 
will be forced out mechanically with the water. 

The general rule to be followed in the majority of cases is this : 
the quantity of fluid used should be small, not exceeding 300 c. cm., 
and should be slowly injected under slight pressure. It is best to 
have the patient lying on the left side with the pelvis raised. 
This amount of fluid should be retained for several hours, so as 
to cause a gradual softening of the intestinal contents or a stimula- 
tion of the smooth muscle fibers of the bowel wall. I generally 
leave orders to have these enemata given at night, so that the bowels 
move the next morning, or else given in the morning, so as to obtain 
a movement in the evening. Glycerin, soap, sugar, honey, etc., 
added to the enema increase the softening effect upon the fasces. 
Penzoldt's 1 experience, which I can substantiate throughout, was 
that soap acted most energetically in this respect, and oil somewhat 
less so. Others have recommended limewater for the same pur- 
pose. As a rule, I order the following as an effectual enema : One 
teaspoonful of soap shavings, or of good glycerin soap, dissolved in 
a quarter of a litre of lukewarm water to which is added one to 
two tablespoonfuls of glycerin. As a result of Fleiner's 2 recom- 
mendation, oil injections of from 400 to 500 c. cm. are very fre- 
quently used. Fleiner believes that it is very important to use 
only the purest oil, and for this purpose he has especially recom- 
mended sesame oil. The disadvantage of the method is that fre- 
quently the patient's clothes are soiled by the oil. For this reason, 
and also because the oil partly adheres to the walls of the irrigator 
and tube, I order the oil to be used in the form of an emulsion, and 
recommend the following procedure : A piece of soda the size of a 
bean is dissolved in a quarter litre of water ; to these are gradually 
added two tablespoonfuls of commercial cod-liver oil and the mix- 
ture thoroughly shaken ; two tablespoonfuls of castor oil are then 
added, and the whole mixture shaken until an emulsion has been 
formed. The resulting emulsion readily flows through the irrigator, 
is well retained by the patient, and even in the most obstinate 
cases will succeed in softening hardened faeces. In an experience of 



180 DISEASES OF THE INTESTINES 

almost ten years I have never seen any irritation, pain, or other 
unpleasant symptoms from them, and I therefore warmly recom- 
mend them. 

In this place it is proper to discuss " high enemata," concerning 
which much is said in daily practice, and to the mechanism of 
which due consideration is seldom paid. We have already noted 
that rectal tubes can seldom be introduced beyond the sigmoid 
flexure or the descending colon, since they are generally arrested in 
the sigmoid flexure, and further attempts result in a bulging of the 
intestinal wall. It is no better with rigid French or English tubes 
than with the soft Nelaton tubes ; the former pass more readily into 
the sigmoid flexure, although they are very apt to be arrested by the 
folds of this portion of the intestines. We see, therefore, that the 
whole question of the so-called high enemata is in many respects an 
illusion. 

Even for extensive lavage of the upper portions of the intestines 
it is not necessary to introduce the tube very high. By means of 
auscultation one may convince himself that even when the tube lies 
in the rectum if the patient is properly placed (lying on his [left] 
side with raised pelvis, or in the knee-chest position), fluids pass as 
far as the cecum. 

Irrigations of the bowel by means of a funnel are especially use- 
ful for the removal of fsecal masses and tightly adherent mucus 
from the large intestine. In obstinate constipation I have had very 
good results from enemata consisting of several litres of soapsuds 
(with the addition of glycerin, castor oil, and cod-liver oil if neces- 
sary). 

Indications for Enemata and Irrigations of the Intestine. — Ene- 
mata are most frequently used in acute and habitual constipation. 
Regarding their usefulness or disadvantages there is a diversity of 
opinion among physicians and laymen. We cannot here enter into 
this question. From my own experience, I believe that enemata 
have a wide field of application both in acute and in habitual con- 
stipation ; when properly given they are generally successful. They 
are said to have the disadvantage of distending the large intestine 
and thus increasing its atony. This is certainly true where very 
large enemata are given. When given as recommended by us this 
result need not be feared. Therefore, whenever possible in habitual 
constipation enemata should be given preference to laxatives. An 
internal laxative is best in acute constipation complicated by acute 
gastric catarrh. The second most frequent indication for enemata 



INJECTIONS 181 

is chronic catarrh of the large intestine with profuse diarrhoeas or 
excessive mucus formation. Here one should use lukewarm water, 
or, better still, physiological salt solutions or solutions of medicinal 
agents. The latter should be chosen according to the effect desired ; 
thus we may use antiseptics such as lysol, boric acid, salicylic acid, 
salicylate or benzoate of soda, thymol, etc., or astringents such as 
tannin, aceto-tartrate of aluminium, and nitrate of silver,* or mucus 
solvents such as boracic acid, or bicarbonate, carbonate, or acetate 
of soda,f or limewater. Here intestinal lavage is much better than 
enemata, for it enables us to first cleanse the bowel and then imme- 
diately thereafter apply our medication. If tenesmus occurs, it may 
at once be allayed by lowering the funnel. The lavage should be 
repeated once or twice daily. 

A further indication for lavage is furnished by chronic stenoses, 
where these are not caused by extensive ulcerations or tumours 
which tend to perforate. Since we have no general diagnostic crite- 
rion for these conditions, great care must always be exercised — 
i. e., avoid great pressure, and give only small enemata, frequently 
repeated. Syringes which force fluids into the gut should never be 
used. While the effect from these irrigations is mainly palliative, 
skilful application may occasionally enable us to relieve a sudden 
and dangerous total intestinal obstruction arising from dietary error 
— e. g., impaction of indigestible food remnants. 

It is sometimes possible to loosen and wash out gallstones, cop- 
roliths, or swallowed foreign bodies causing an obstruction. In 
obstruction from gallstones I would recommend the employment 
of injections of chloroform water (10 : 1,000) in order to dissolve 
small fragments of these concrements. This should be done under 
anaesthesia, as it is then possible to pass beyond the ileo-csecal valve. 
I have not had any practical exj)erience in the matter. 

Furthermore, enemata are indicated in acute and chronic invagi- 
nations : in the acute, in order to reduce the invagination ; in the 
chronic, to prevent or relieve coprostasis above the invaginated 
portion, ^othnagel especially recommends injections of 5 to 8 per 
cent saline solutions, and bases his recommendation upon animal 
experiments, in which he found that physiological invaginations are 
overcome by saline injections. 

* We use one teaspoonful of tannin, boric acid, and aceto-tartrate of aluminium, 
or one half to one gram of silver nitrate to the litre of water. 

\ Bicarbonate, carbonate, or acetate of soda are used in the strength of one 
dessertspoonful to the litre. 
13 



182 DISEASES OF THE INTESTINES 

Intestinal Douche. — In the intestinal douche we have a means 
of stimulating and strengthening the neuro-muscular apparatus of 
the lower portion of the large intestine. Here, as in the stomach, 
we employ a funnel and rubber tube armed with a short, soft, Nek- 
ton rectal tube, the end of which contains ten to fifteen small open- 
ings. The tube is introduced as far as possible, preferably under 
the guidance of the finger. Ordinary cold water, or cold water 
alternating with hot, is employed, or we may also use water charged 
with C0 2 . As already mentioned, it is best to have the rectum 
emptied before giving the douche. 

In a series of cases of atony of the large intestine, especially in 
those in which scybala were retained in the recesses of the sigmoid 
flexure and the ampulla of the rectum and caused marked tenes- 
mus, this procedure has proved a very valuable one. 

2. Inflation of Air 

Inflation of air, the diagnostic value of which has already been 
discussed, is warmly recommended by some writers as a means of 
relieving obstructions, especially of the lowermost portions of the 
intestine. Curschmann 3 , in particular, has often spoken in favour 
of intestinal insufflation in cases of volvulus of the sigmoid flexure 
and intestinal stenoses, and he prefers it to the injection of water. 
He recognises, however, that there are dangers connected with the 
procedure, and therefore advises that it should be employed with 
great caution in specially selected cases. The recommendation of 
Curschmann, to use a tube of such a form as to permit the entry 
and exit of air at will, is certainly worthy of consideration. It is 
more difficult to fulfil Curschmann' s second condition — namely, the 
selection of suitable cases. Thus, it is often impossible to determine 
whether ulceration of a carcinoma of the colon has occurred and if 
there is danger of rupture. It is often exceedingly difficult to de- 
termine the nature of a stenosis. I believe that all stenoses due to 
ulceration or tumours constitute a contra-indication to insufflation 
with air. It is also advisable not to attempt this procedure in 
invaginations low down, as one can never determine with certainty 
how far the process has advanced (beginning gangrene). Careful 
insufflation may be done in simple volvulus of the sigmoid flexure 
when the diagnosis is certain. 



INJECTIONS 183 

3. Gastric Lavage in Intestinal Diseases 

Gastric lavage in intestinal diseases comes up for consideration 
in stenosis or stricture of the bowel, above which fsecal matter has 
collected; also where fermenting stomach contents exercise an 
unfavourable influence upon the intestines. In the latter case, how- 
ever, the retention of stomach contents in itself constitutes an 
indication for gastric lavage. Lavage may be advisable, though not 
necessary, in patients in whom an excessive production of acid or 
of mucus in the stomach causes an irritation of the mucous mem- 
brane of the small intestine, and frequently a resulting diarrhoea. 

In general, lavage of the stomach is done for stenosis or stricture 
of the small intestine ; but in obstruction or occlusion of the large 
intestine, according to numerous writers, it is often a life-saving pro- 
cedure. The credit for having first tried and recommended gastric 
lavage in obstruction must be given to Kussmaul and his disciple 
Calm 4 . From the observation of three cases, they showed that by 
meaus of this procedure cases of ileus with a bad prognosis could 
sometimes be cured. Soon after Senator-Hasenclever 5 , Kiister 6 , 
Henoch 7 , Ewald 8 , Kauffmann 9 , Kuhn 10 , Curschmann 5 , Pollak 11 , 
and others reported successful cases, and at the present time we 
are justified in considering gastric lavage as a useful procedure, 
scarcely less important than opium. 

As Eothnagel 12 quite properly observes, we must not expect too 
much from gastric lavage ; indeed, that procedure at times may not 
only be ineffectual, but even harmful, since it can further diminish 
the already exhausted strength of the patients. The results from 
lavage would depend upon the nature of the obstruction and our 
ability or inability to overcome it by diminishing the pressure 
above. Since the nature of the obstruction in acute cases can 
usually not be determined, it can be readily understood that gastric 
lavage may be a life-saving procedure in one case, while in another 
case its effect will be an entirely negative one. 

One point, however, should always be borne in mind : Gastric 
lavage should always be resorted to in the early stages of ileus. 
The more violent and fgecal the vomiting, the greater the indication 
for gastric lavage. For we recognise in faecal or feculent vomiting 
a certain sign of a marked putrefaction of the stagnating contents 
above the site of strangulation, and only through the relief of this 
condition can we check the violent peristalsis of the bowel and the 
stagnation of its contents. As a rule, therefore, lavage is only in- 



184 DISEASES OF THE INTESTINES 

dicated in those cases of ileus which have not progressed for more 
than twenty-four to forty-eight hours. In exceptional cases, the 
period when the general condition of the patient is a good one, 
lavage may be tried at a later period of the affection. Where there 
is already beginning heart failure, a miserable, rapid pulse, and 
possibly, too, impending death, the chances of accomplishing any 
benefit whatever with the procedure are very slim indeed. If a case 
such as that of Pollak * is now and then reported, in which, under 
most desperate conditions, a cure was effected, it only demonstrates 
the utmost extreme in which lavage may be of benefit. In private 
practice it is not always easy to resist the urgent wishes of those 
interested in the patient, who want every measure tried which can 
possibly save the patient, particularly if nothing can be lost and 
possibly much gained thereby. It will always be well, however, 
to point out the fact that such a mechanical procedure in the late 
stage of the affection may hasten the fatal termination of the case. 

The condition which presents itself in chronic stenoses, and the 
indication for its relief, is much simpler. Of these stenoses, those of 
the small intestine, particularly of the duodenum (supra- and infra- 
papillary), call for washing out of the stomach. The conditions are 
so much like those of stenoses of the pylorus that they are to be 
treated just like the latter. We must not wait, therefore, with 
lavage until vomiting becomes incessant, but should begin as soon 
as the stomach contents give evidence of stasis (in infrapapillary 
stenosis, bile- stained or feculent). 

It is quite evident, however, that only in rare cases can we secure 
permanent relief of the stenosis by lavage. 

Techxic of Gastric Lavage ix Ixtestixal Obstruction and 

Stenosis 

This differs in a few points from ordinary methods of lavage. 
In the first place, the stomach must be washed out several times 
daily (two to five), and the washing must be continued each time 
until the stomach is entirely empty. The succeeding lavage must 
not be delayed until vomiting again occurs, but must be done as 
soon as fsecal matter again enters the stomach. This will be shown 
by renewed distention of the stomach, which has become less promi- 
nent immediatelv after the former lavage. The fact that onlv clear 
water flows away with the first washing must not deter us from fur- 

* Loc. cit. (Case IV). 



INJECTIONS 185 

ther lavage, particularly where the patient has previously vomited 
large quantities. I usually give a centigram of morphin subcutane- 
ously before washing out the stomach. I have never had occasion 
to cocainize the pharynx. A hypodermic injection of caffein or 
camphor may be necessary previous to the lavage. Skilful technic 
(compression of the tube upon its withdrawal (Ewald) ) will enable 
us always to avoid aspiration. The pulse is to be carefully watched 
in very weak individuals. The technic of gastric lavage in chronic 
stenoses differs in no wise from that of stenoses of the pylorus. 
Here, too, once a day, best in the morning, is sufficient ; or in the 
evening, where rest is disturbed by the decomposition of the stag- 
nating products. 

LITERATURE 

1. Penzoldt. In Penzoldt-Stintzing's Handbuch, Bd. iv, S. 520. 

2. Fleiner. Berliner klin. Wochenschr., 1893, No. 3 u. 4. 

3. Curschmann. Deutsche med. Wochenschr., 1887, No. 21, and Verhand- 

lungen d. VIII. Congr. f. innere Medicin, 1889. (Compare the instructive 
discussion recorded there.) 

4. Cahn. Berliner klin. Wochenschr., 1884, S. 669. 

5. Hasenclever. Berliner klin. Wochenschr., 1885, S. 65. 

6. Kuster. Ibid., 1885, No. 27 u. 28. 

7. Henoch. Ibid. 

8. Ewald. Ibid. 

9. Kauffmann. Vereinsbl. der Pfalzer Aerzte, iii, S. 185. 

10. Kuhn. Bulletin general de Therapeutique, 1885, 15 Juliet. 

11. S. Pollak. Wiener med. Wochenschr., 1892, No. 51, and 1893, No. 1 u. f. 

12. Nothnagel. Die Erkrankungen des Darms u. Peritoneum, S. 406. 



CHAPTER XII 
MEDICINAL TREATMENT OF INTESTINAL DISEASES 

1 . Cathartics 

By cathartics we understand those remedies which are capable of 
ridding the intestines of their contents within a short time. Since 
earliest times these have been divided into mild (eccoprotica swe 
lenitiva) and powerful cathartics (ch % astica). Between these classes 
there is a middle class, the so-called neutral salts, which belong to 
one or the other classes according to dosage employed and the indi- 
vidual effect obtained. 

In spite of numerous investigations (confined for the most part, 
however, to animals), our knowledge of the action of cathartics is 
very limited. The effect of an individual cathartic varies in all 
probability with its chemical state. This accounts for the variety 
of action observed. Thus castor oil acts only after emulsification 
by the pancreatic juice and the bile ; gamboge, elaterium, jalap, and 
scammony act similarly. 

Calomel is changed in the small intestines; a portion of it is 
converted into corrosive sublimate. We do not know in what man- 
ner this substance acts ; all mercurial salts cause increased catharsis. 
It is probable that the action of this drug begins in the upper part 
of the intestines, while other cathartics, such as senna, aloes, and 
colocynth, exert their main action upon the large intestine (Nasse, 
Radziejewski). 

The action of the neutral salts appeared easiest of explanation. 
It was natural to suppose that their action was due to a transuda- 
tion. As great an authority as Liebig supported this theory ; he 
was followed by French investigators, chief among whom was Pois- 
seuille. Later Aubert 1 opposed this theory, while Moreau 2 advo- 
cated it. Radziejewski 3 regards the influence upon peristalsis as 
the main principle in the action of cathartics. Brieger 4 showed 
that the action of laxatives is due to stimulation of peristalsis ; neu- 
tral salts in addition cause an increased secretion of water and a 
larger secretion from the glands of the intestinal mucous membrane ; 
186 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 187 

finally, that drastic cathartics in small doses act like laxatives, while 
in larger doses they cause an inflammatory exudate and a hyper- 
secretion. 

These unsatisfactory results include all that we know of the 
theory of the action of cathartics, and we must therefore place our 
dependence upon experience gained in daily practice. 

In this connection my experience leads me to emphasize that 
every cathartic, or group of cathartics, has clinically a distinct action, 
and therefore distinct indications. For example, in acute constipa- 
tion, castor oil, which acts rapidly and painlessly, is first to be con- 
sidered ; in acute indigestion, with or without bacteriological basis, 
calomel in large, rapidly repeated doses is useful. The use of the 
neutral salts or bitter waters is indicated in bilious individuals with 
hemorrhoids. Between these two are a whole series of other cathar- 
tics whose use is not especially indicated, but which are valuable 
only when varied, since most of them lose their action after a time. 
The physician should, however, have a knowledge of the main 
and secondary action of these remedies, and make his own indi- 
cations. 

Opium and belladonna occupy a special position among cathar- 
tics. We shall recur later to the effect of these substances upon 
the intestines. In this connection it need only be mentioned that 
they should be used where spastic contraction prevents the intes- 
tine from emptying itself. Lead colic is a typical example of this. 
In spastic affections of the intestine, flatulent colic, stenosis of the 
intestines, and in ileus, one can accomplish more by overcoming 
the spasmodic contraction of the bowels than by the use of cathar- 
tics themselves. 

A large number of cathartics, once very much in favour, have 
now become obsolete. Among these substances we may mention 
agaricus, euphorbium, fructus colocynthidis, gamboge, hellebore, 
herba gratiolse, leptandra virginica, metallic mercury, elaterium, 
croton oil, scammonium, and jalap tubers. A number of other 
remedies might with justice meet with the same fate. The follow- 
ing, on the contrary, are recommended if used under proper indica- 
tions : castor oil, olive oil, calomel, magnesium salts, cascara sagrada, 
rhubarb preparations, tamarinds, podophyllin, precipitated sulphur, 
tartrate of soda, frangula bark, senna leaves. 

With the exception of glycerin, subcutaneous and rectal admin- 
istration of cathartics (aloes, etc.) has heretofore been but little 
employed in medicine, although the subcutaneous employment of 



188 DISEASES OF THE INTESTINES 

physostigma for cathartic purposes has been well established in 
veterinary practice. 

Indications for the Use of Cathartics 

We mnst here differentiate between acute and chronic (habitual) 
constipation. The employment of cathartics in the first-named 
condition will depend principally upon the cause of the consti- 
pation — acute gastric catarrh, initial stage of acute infectious dis- 
eases, acute intestinal obstruction, typhlitis, appendicitis, invagina- 
tions, etc. 

The employment of cathartics is indicated only where we can 
exclude inflammatory processes and displacements of the intestines. 
As long as there is any doubt, and there is no indication for active 
treatment of the acute constipation, one should limit himself to 
enemata, which can never do much harm. When there is a neces- 
sity for cathartics in acute constipation, a rapidly acting and certain 
cathartic should be used. If there are many stomach symptoms, 
calomel is to be recommended ; where there are none such, castor 
oil is preferable. The various rhubarb preparations are valuable, 
but these lack the thorough action of the cathartics just named. 
JSfo others need be considered in these cases. 

In treating these conditions it should be remembered that cathar- 
tics should be stopped as soon as possible ; it is therefore advisable 
not to give too small doses. If after one or more doses the con- 
stipation recurs (which is frequently the case), it is advisable to 
treat the patient according to the principles previously laid down — 
i. e., by dietetic measures. 

In chronic (habitual) constipation the indication for the use of 
a cathartic, and the selection of the one to be used, depend upon 
the nature of the affection. We must distinguish between condi- 
tions in which the patency of the intestinal canal is diminished, 
whatever be the situation or the cause, and those in which the lumen 
of the bowel is unobstructed. 

In the former class of cases, especially in stenoses of the intes- 
tine, cathartics are generally indispensable and symptomatically 
useful. Since a stasis of faecal contents which is favourable to 
decomposition processes develops above the point of stenosis, cathar- 
tics are preferable to enemata, even when stenosis is situated low 
down. Enemata are generally without result. 

The kind of cathartics to be used is a question of great impor- 
tance ; those only should be selected which do not cause painful 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 189 

spasmodic contraction and thus create a danger of perforation. 
These are the mildly acting preparations of rhubarb, compound 
licorice powder, magnesia usta, sodium phosphate, preparations of 
tamarind and cascara sagrada, tea of frangula bark, etc. Prepara- 
tions of aloes, bitter waters, podophyllin, and the senna preparations 
are to be used with caution. 

In the second class of cases — i. e., those in which the permea- 
bility of the bowel is preserved — the character of the disease deter- 
mines the method of treatment to be pursued. In my opinion 
cathartics should be used only in desperate cases of constipation, 
and in old people in whom the normal reflex excitability of the 
intestinal muscle has disappeared. Here one should endeavour to 
use small doses of the milder aperients. Aided by a stimulation of 
intestinal activity by proper diet, this procedure will often, though 
not always, be successful. 

The habitual use of cathartics in young persons is to be 
avoided. After a misuse of these for years, it is very difficult to 
succeed in bringing back normal peristalsis. I have already men- 
tioned (page 149) that even in such cases one can sometimes obtain 
good results. 

Contra- indications to the Use of Cathartics 

In acute affections, in which the diagnosis of occlusion of the 
intestine is certain, the use of cathartics is contra-indicated. In 
the early stages of an acute intestinal affection, which later proves 
to be a case of intestinal obstruction, one can not blame the physi- 
cian for having given a cathartic. In the later stages, where the 
symptoms of intestinal obstruction are clear, it is an error to give a 
cathartic. The same holds true for acute inflammatory affections 
of the type of an appendicitis. Our present knowledge of the 
nature of this disease (appendicitis) allows us to diagnosticate a 
typhlitis stercoralis in exceptional cases only, so that it is always 
advisable to keep in mind the possibility of a primary disease of 
the vermiform appendix. If, notwithstanding, there is reason for 
emptying the bowel, enemata are indicated (see page 180). When, 
in exceptional cases, there is a particular reason for one dose of a 
cathartic, castor oil is by all means the surest and best drug to 
use. It is far preferable to the saline cathartics, bitter waters, 
or rhubarb. In this connection we must mention that cathartics 
are also contra-indicated in the habitual constipation which so fre- 
quently follows appendicitis. In most cases the patients do well 



190 DISEASES OF THE INTESTINES 

with proper feeding, or good results may be obtained from enemata, 
glycerin suppositories, etc. 

Cathartics are contra-indicated in young people who have 
been constipated for a short time only. In children cathartics 
are absolutely contra-indicated, and their employment can not be 
too strongly condemned. In these cases continued and energetic 
care in feeding, combined, perhaps, with massage and gymnastics, 
gives good results. One should try dietetic measures for several 
weeks before resorting to the constant employment of cathartics. 
These drugs are contra-indicated in chronic gastric and intesti- 
nal catarrhs. As regards the former, I have gained the impres- 
sion that cathartics have an unfavourable influence upon the 
secretion of the gastric juice. This seems to me to be the 
reason why we more frequently meet with insufficiency of gastric 
secretion in women than in men, though the latter are more apt 
to acquire gastric affections on account of their use of alcohol and 
nicotin. 

Still more important is the contra-indication to the continued 
use of purgatives in chronic enteritis, affecting either the small or 
the large intestines. A careful observer who is accustomed to 
make frequent examinations of the faeces will doubtlessly have 
recognised that a slight enteritis of short duration, unnoticed by 
the patient, results not only from continual use of cathartics, but 
may also follow one or two doses of a mild laxative. This is much 
more marked where drastic cathartics are habitually employed, and 
I feel I am not exaggerating when I maintain that the more fre- 
quent occurrence of membranous enteritis in women is due to care- 
less employment of laxatives. This is already shown from the 
fact that the mucous secretion ceases at once, and in most cases 
permanently, when intestinal functions are regulated by physio- 
logical laxatives. In the special part of this work I shall illustrate 
this by a series of histories.* 

2. Antidiarrhoeal Remedies 

Since earliest times medicinal remedies have played an important 
role in the treatment of chronic diarrhoea. They are believed either 
to inhibit peristaltic action, thereby creating better conditions for 

* von Noordeu, in a very remarkable article upon membranous enteritis (Zeit- 
sehr. fur prakt. Aerzte, 1898, No. 1) takes a stand which I maintained a number of 
years ago (cf. Deutsch. med. Wochenschr., 1883, S. 1000). 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 191 

the absorption of nutritive material from the intestinal canal, or 
restrict the production of intestinal secretion, or finally to cause 
neutralization of certain fermentative processes in the intestines. 
Antidiarrhoeal drugs are furthermore employed to furnish a pro- 
tective covering for intestinal ulcers, in so far as these are the cause 
of the diarrhoea and thereby to exert a curative effect upon the 
latter. Some remedies (calomel, tincture of rhubarb, belladonna, 
etc.) are laxative in large doses but binding in small ones. There 
are some drugs, too, which exert a beneficial influence in diarrhoea 
without our being able to explain their action. 

The correctness of the above statement of the action of drugs 
in diarrhoea may be disputed ; certain it is, however, that acute and 
chronic diarrhoea frequently are cured when drugs are administered. 

1. Remedies which inhibit peristalsis : 

These include opium and its alkaloids (morphin, codein, nar- 
cein, and papaverin), as well as atropin and the belladonna prepara- 
tions (particularly in small doses). 

2. Remedies which act upon the intestinal mucous membrane 
(astringents) : 

These include tannic acid (tannin) and its preparations, tannigen 
(diacetyl tannic acid) and tannalbin (tannin albuminate). Among 
other remedies which contain tannic acid may be mentioned Colombo, 
catechu, hsematoxylon, cascarilla, ratania, oak bark, cotoin, and 
paracotoin. Nitrate of silver should also be classed with the intes- 
tinal astringents. 

3. The antifermentative remedies include calomel, salicylate of 
bismuth and beta-naphthol bismuth (orphol), nosophen, paraform, 
tannoform, creosote, salol, beta-naphthol, etc. 

4. The remedies which furnish a protective coating include 
carbonate and phosphate of calcium and similar chalk preparations 
(pulvis cretge, talcum preparations, bismuth, etc.). 

The Indications foe and Use of Antidiarrhoeal Remedies 

Antidiarrhoeal remedies are administered by mouth or as sup- 
positories (opium, morphin, belladonna, etc.), or finally as rectal 
injections. Only rarely are they given subcutaneously . For rectal 
injection, tannin, nitrate of silver, aluminium (preferably the aceto- 
tartrate salt) or boracic acid are best. They are useful in diseases 
of the large intestine only, while the internal remedies are to be 
used in catarrhs of all parts of the bowel. 

In some cases it is easy to determine which remedy to employ ; 



192 DISEASES OF THE INTESTINES 

in others the difficulty of correctly interpreting the action of the 
remedies makes the selection of the proper one in a given case 
less easy. 

Thus the use of antidiarrhoeal remedies is clearly indicated in 
acute affections following exposure or errors in diet. The question 
arises in these cases : Should the remedy be given at once, or only 
after the bowels have been sufficiently emptied ? In weak individ- 
uals the immediate administration is in general the better proce- 
dure ; but where the general condition is very good, we should not 
be too eager to check a diarrhoea, particularly if this be accompanied 
by fever (beginning typhoid, infectious gastro- enteritis, etc.), or if 
there be an epidemic of cholera. On the contrary, it is much better 
to keep up the diarrhoea for several days by the administration of 
calomel — large doses at first, smaller ones later. 

If none of these complications be present, we must give a 
rapidly acting and certain astringent remedy. Opium is the only 
one to be considered, and should be given in the form of the tinc- 
ture, the powder, or the extract, combined, perhaps, with the tincture 
or the extract of belladonna. All other drugs, as well as any other 
combination with opium, are superfluous. As a rule, it is better to 
give the opium by the mouth than by the rectum ; only where there 
is pronounced nausea or marked tenesmus should opium be given 
per rectum, and then in the form of suppositories combined, perhaps, 
with belladonna extract. Morphin, codein, papaverin, and other 
alkaloids of opium are inferior to the mother drug in their action. 
Not enough is known about subcutaneous injections of the watery 
extract to allow one to express an opinion as to their efficiency. 

Opium, whenever indicated, should be given in effective doses, 
but continued for a short time only. I would strongly warn against 
small divided doses. The correct amount for an adult is twenty 
drops of the tincture two or three times a day, or two or three doses 
of the extract, each equal to 0.05 gram. With this and proper feed- 
ing an acute intestinal catarrh is generally cured. For eight to ten 
days the patient must be instructed in rules of diet (see section on 
Diet). The main use of opium is in acute g 'astro-enteritis ; it is 
not a remedy for prolonged employment. 

The other drugs above mentioned are used in a variety of ways 
and combinations in subacute and chronic diarrhoeas, especially in 
those affecting the small and upper part of the large intestine. If 
we were to believe the praises which have been sung in medical 
literature about these drugs, especially during the last decade, the 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 193 

treatment of chronic intestinal catarrhs, even those of a tubercular 
variety, would seem to be as promising and simple as anything in all 
internal medicine. The critical physician would naturally doubt 
this statement if for no other reason than for the fact that new 
pharmaceutical remedies are being continually produced and recom- 
mended. 

I have not seen any lasting influence upon chronic diarrhoeas 
from any of the newer antidiarrhoeal remedies. My experience in 
this respect has been a large one. My results in the treatment of 
these conditions on exclusively or almost exclusively dietetic prin- 
ciples (about which the most important facts have already been 
stated) have been just as good as when the newer remedies were 
used. The so-called antiseptic astringent remedies would be ideal 
if they exerted an influence upon the disease without simultaneous 
dietetic treatment, and if they were able to influence the mucous 
membrane in such a manner that the intestine would gradually 
become able to bear almost normal regime without difficulty and 
without the occurrence of diarrhoeas. There is no real value in a 
constipating action jper se of drugs. 

It is true, I believe, that we can use antiseptic or astringent 
drugs as adjuvants to our dietetic and hygienic methods. The heal- 
ing of an intestinal catarrh can be accomplished only by long-con- 
tinued care of the intestines as has been described above, and in 
connection with long-continued absolute rest in bed. Whoever 
looks for impressive results will without doubt find great satisfaction 
from modern antiseptics and astringents ; but whoever desires to 
make a permanent cure of a chronic diarrhoea can not place a very 
high value upon these remedies. 

The indication for the application of astringent remedies per 
rectum is limited to chronic catarrhs of the large intestine. I 
have sometimes seen favourable results from tannin and nitrate of 
silver, but have obtained much better results from aceto tartrate 
of aluminium (one teaspoonful to the litre of water). It must be 
mentioned, however, that astringent remedies can not only cure 
catarrhs, but may cause or aggravate them. Great care in the 
administration and close observation of the reaction following such 
astringent injection is imperative. It is advisable to follow an 
enema of nitrate of silver by a neutralizing injection of salt solu- 
tion. 



194 DISEASES OF THE INTESTINES 

CoNTRA-INDICATIONS TO THE USE OF AnTIDIARRHCEAL E-EMEDIES 

Above all, antidiarrhoeal remedies are contra-indicated where the 
apparent symptoms are those of diarrhoea, but the real condition is 
one of constipation. These remedies should not be employed in 
the diarrhoea which accompanies intestinal stenosis. In carcinoma 
of the rectum there are frequent apparent diarrhoeas which must be 
considered as decomposition products of stagnating intestinal con- 
tents. Cathartic measures would be indicated in such a case. It 
is also best to administer them to patients with alternating diar- 
rhoea and constipation. In these it is advisable to wait several days 
before giving drugs, in order to come to some conclusion as to the 
nature of the intestinal disturbance. Several years ago I had occa- 
sion to observe a case in which the conditions were so complicated 
that careful observation for several weeks was necessary before it 
could be determined that the patient had chronic constipation, and 
not chronic diarrhoea. The patient, who was very ill, was cured 
when the constipation was overcome. Among the remedies contra- 
indicated in chronic diarrhoea, opium and calomel should be men- 
tioned, as they are frequently wrongly used. Although I place a 
high value upon opium as a remedy in many diarrhoeas, I always 
hesitate before using it in the chronic form. It is true, one gains 
the advantage of placing the bowels at rest for a short time, but 
meanwhile they become filled with putrefying decomposed material, 
which only reproduces a severer diarrhoea as soon as the opium 
effect has passed off. I allow the use of opium preparations as a 
palliative method only during travel, in society, etc., but even then 
with the greatest reserve. I need hardly mention that when there 
is a suspicion of ulcerations of the intestines calomel must not be 
used, or, if so, only under restrictions. 

3. Sedative Remedies 

Owing to the great importance of these in the therapeutics of 
intestinal affections, it is necessary to dwell briefly upon their 
significance and use. They include mainly opium and its principal 
alkaloid, morphin (which in this respect is superior to codein, 
papaverin, narcein, etc.), and belladonna with its alkaloid, atropin. 

From experimental investigations very little has been learned 
regarding the manner in which opium and its alkaloids act. !N*oth- 
nagel's 5 opinion that the intestinal paralysis results from stimulation 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 195 

of the inhibitory fibres of the splanchnic is directly opposed to that 
of Jacob] 6 and Pohl ', who, after extensive researches, have come 
to the conclusion that the paralyzing effect of opium is brought 
about by diminished excitability of the intestinal wall. The latest 
investigations of Z. von Yamossy 8 tend to show that there is a 
benumbing of the brain centres which prevents transference in the 
brain of centripetal impulses of the pneumogastric to those centrif- 
ugal nerve paths that control intestinal movements. 

We can not here give more than this brief reference. It shows 
sufficiently well, however, that we still have had no satisfactory 
explanation of the action of opium. 

As regards belladonna and atropin, it is assumed that they cause 
paralyses of the intestinal wall, and thus relieve abnormal contrac- 
tions of the intestinal coils. 

We know more, however, about the clinical application of nar- 
cotics. The following are the indications for their use : To allay 
inflammation, to relieve painful contractions, to arrest increased 
intestinal peristalsis accompanied by profuse evacuations of contents, 
and, finally, to secure rest of the entire intestines, so as to permit of 
a correction of intestinal knottings, invaginations, incarcerations, and 
volvuli. 

Appendicitis furnishes the best example for the use of opium in 
inflammatory processes. We should, however, make a careful dis- 
tinction between the various stages of this affection. In appendi- 
citis, opium is only indicated when symptoms of irritation, fever, 
pain, and meteorism are present, and the patient's condition is still 
satisfactory. If these symptoms disappear after repeated large 
doses of opium (e. g., tinct. opii gtt. xx every three hours, or extr. 
opii 0.03 gm. t. i. d.), its further use, though not harmful, is no 
longer necessary. If the opium is continued the dosage should be 
reduced one half. If symptoms of irritation have been present for 
three or four days, opium is contra-indicated, for then there de- 
velop intestinal paralyses, which are overcome only with the great- 
est difficulty. 

If symptoms of irritation continue and those of collapse (rapid, 
compressible pulse, general depression, etc.) begin to appear, opium 
must at once be stopped. This is the stage in which opium, as sur- 
geons very correctly claim, masks the disease and gives rise to false 
hopes. 

A similar rule applies to acute intestinal occlusions. Here also 
opium is indicated in the early stage with symptoms of reaction. 



196 DISEASES OF THE INTESTINES 

If opium does not then yield the desired results, a curative action 
can no longer be expected from it ; it can only induce euthanasia. 
The same objections against the giving of large doses apply as in 
appendicitis. Undoubtedly large doses of opium temporarily relieve 
the seriousness of the condition, but actual benefit can no more be 
expected than from an infusion of digitalis in a cardiac case with 
impending paralysis. The pulse and general condition should guide 
us in the management of acute intestinal obstruction. If these are 
good and the features " composed " (von Leyden), opiates will at least 
do no harm ; if these are not good, then opium can only help seal 
the patient's fate. 

A few words regarding the treatment of enteralgias, intestinal 
colic, peristaltic restlessness, and acute diarrhoeas. Whatever may 
be the etiology of these conditions, narcotics will always be of bene- 
fit, for they quiet the excessive peristalsis, relieve pain, and thus 
enable solid contents to pass through the intestinal canal, and fluid 
contents to become more solid. 

In a given case it is by no means immaterial whether we admin- 
ister opium or one of its alkaloids (particularly morphin) or bella- 
donna (or atropin). This has been sufficiently shown by clinical 
experience. Opium is far superior to any of its alkaloids in quiet- 
ing the intestines or in arresting peristalsis. Morphin has only the 
analgesic property of opium. In any case in which we desire a 
sedative effect upon the intestines, as well as a slowing or an arrest 
of peristalsis, opium will be found superior to all other narcotics. 

On the other hand, extract of belladonna in doses of 0.01 to 
0.03 gram, and its alkaloid, atropin, in doses of from 0.005 to 0.001 
gram, are indicated in all colicky and painful crises. Like the opi- 
ates, they may in such cases even have a laxative action. In gen- 
eral, their action is weaker than that of the opiates ; their long-con- 
tinued employment is always attended by danger of poisoning. 
Opiates are frequently combined with belladonna. 



4. Remedies for Flatulence 

Since early times a large number of remedies have had the 
reputation of allaying flatulency, either through combination with 
the gases or excitation of the intestinal motility, or through 
other unknown ways. As regards the power to combine with 
gases, the magnesia salts, especially magnesia usta, play an impor- 
tant part. It is well known that outside of the body magnesia usta 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 197 

can absorb a large quantity of carbonic-acid gas (1 gram absorbs 
about 1,100 cubic centimetres). To what extent this substance can 
absorb gas in the gastro-intestinal canal is still a matter of ques- 
tion. In the stomach, magnesium chlorid is formed bj combina- 
tion with hydrochloric acid ; in the intestines only the residue of the 
magnesia usta can be converted into magnesium carbonate. It is 
very probable, too, that this formation of carbonate of magnesia 
does occur in the intestinal canal, for, after the ingestion of mag- 
nesia, patients frequently have borborygmi and expel much gas. To 
a certain extent, however, the laxative action of the magnesia may 
cause such symptoms. 

The second group of remedies — i. e., those which excite intes- 
tinal motility — is said to act by increasing the muscle tone. It 
includes nux vomica and its preparations (the tincture, the fluid 
extract, and its alkaloid, strychnin), as well as extract of physo- 
stigma. We will speak of these more in detail in the next division. 

Very little is known of the action of the so-called carminatives. 
But here, as everywhere in science, experience is the best guide, 
and it has shown us that in flatulency very great benefit is often 
derived from the use of carminatives. 

The carminative remedies include various so-called carmina- 
tive teas, such as valerian, fennel, peppermint, caraway, anise, 
thyme, and the oils obtained from these substances, the most fre- 
quently employed being oils of menthol, caraway, and fennel. These 
remedies very probably have mild antiseptic properties, such as the 
oil of menthol has been shown to possess. Based on this antiseptic 
property, menthol (0.1 to 0.2 in gelatin capsules) has been recom- 
mended for the relief of flatulency.* The following sums up the 
latest ideas regarding the relative value of the various preparations. 
With teas made from the fruit or leaves there is the additional 
effect derived from the heat. We know from experience that 
heat when applied externally, or hot solutions taken internally, 
exert a beneficial action on acute colic and flatulency. The oleo- 
saccharates and the oils are more in place in the chronic forms 
of flattilencv. The oils are to be given singly or combined, in 
doses of 3 to 5 drops thrice daily, and the oleosaccharates in 
amounts varying from very minute quantities to a teaspoonf ul, also 
thrice daily. The combination of magnesia usta with the so-called 

* To insure solution it is necessary to drink an alcoholic mixture (cognac or 
wine) after the dose is taken. 
14 



198 DISEASES OF THE INTESTINES 

oleosaccharates is very effectual where constipation exists. For 
example : 

^ Magn. ustae 15.0 

Olaeosacch. menthse 5.0 

M. Pulv. Sig. : A quarter to a teaspoonful three times a day. 

In a number of cases of chronic flatulency, pulverized caroway 
fruit in tablet form, in doses of from 0.5 to 1 gram, has proved 
very serviceable to me. 

Charcoal in the form of freshly burnt animal or wood charcoal 
is still very frequently given as a gas-absorbing remedy. In France, 
especially, the " pastilles de Bellocq," which consist mainly of char- 
coal, are very generally used. We can hardly expect any benefit 
from charcoal, however, since it only absorbs gases while it is in a 
dry state. 

5. Tonic Remedies 

Are there any remedies which may rightly be called intestinal 
tonics ? Concerning this subject little has been learned from ani- 
mal experiments. Although there are no exact indications for their 
use, and no convincing results have been obtained, drugs are often 
employed for this purpose. They include the numerous bitters 
which, according to the investigations made by Eamm 9 and Kobert, 
stimulate intestinal as well as gastric peristalsis ; furthermore, the 
preparations of nux vomica are also given (tincture of nux vomica, 
gtt. x-xv, extract of nux vomica 0.01 to 0.03, or nitrate of strych- 
nin 0.001 per dose, preferably subcutaneously). The other bitters 
(tinct. amara, gentian, creosote, etc.) also enjoy considerable repu- 
tation as intestinal tonics. Besides these remedies, I have fre- 
quently obtained good results in painful flatulency from the use of 
the extract of calabar bean. Attention was first directed to this 
drug by Subbotin 10 , and later by S. Schaefer n . 

9 Extr. physostigmse 0.05 

Glycerin ad 10.00 

M. Sig. : Ten drops three times a day. 

Or the same remedy may be given in pill form in doses of 0.005 
gram. It has no laxative action. I have never seen any injurious 
effect result from the extract of calabar bean, and I am convinced 
that in atony of the intestines this drug is as worthy a trial as nux 
vomica. 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 199 

6. Intestinal Antiseptics 

Owing to the numerous investigations of Bouchard and Dujar- 
din-Beaumetz and their scholars, the idea that it is possible to 
disinfect the intestinal canal in fermentative and putrefactive con- 
ditions has been widely accepted, especially in France. These inves- 
tigators have evolved a method of treatment which has been named 
" antisepsie intestinale." Although it had many enthusiastic fol- 
lowers in Germany, this movement has been reluctantly taken up. 
Recently a marked reversal of opinion has taken place in France 12 , 
for the lack of results spoke too strongly against the dogmatic 
certainty with which the new teaching had been proclaimed. 

Regarded critically, the idea of intestinal antisepsis really rests 
upon a very weak foundation ; for we have little knowledge con- 
cerning the manner in which putrefactive products originate in the 
intestines, as well as the factors which increase or diminish them ; 
and, furthermore, we do not know which of these products are 
absorbed and which are not, nor how the various foodstuffs influ- 
ence them. Through the investigations of Rovighi 13 , Schmitz 14 , 
Winternitz 15 , and Albu 16 one fact has been established — that milk 
and its products (kefir and pot cheese) cause a diminution in the 
ethereal sulphuric acids in the urine. Furthermore, it must be 
remembered that inhibition of normal intestinal motility results in 
an increase of putrefactive products. If we compare the conditions 
existing in the stomach with those in the intestines — more complex, 
it is true — we will have a basis upon which to study the question of 
intestinal disinfection. We know to-day that the best way in which 
to disinfect the stomach is to restore to it its normal motility. 
Therefore it must be recognised that by the mechanical evacuation 
of the stomach, numerous fermentative products and their causes 
are removed, and by this means a more favourable condition is 
created. Objectively this is noticeable in a demonstrable increase 
in the strength of the distended organ. If the normal motility be 
lost, permanent disinfection of the stomach, filled as it is with micro- 
organisms, is impossible. 

The knowledge gained from these experiences may be applied 
to the far more complicated conditions in the intestines ; here also 
the best antiseptic remedy is the restoration of normal peristalsis. 
Therefore Albu 17 is perfectly correct if, in his numerous publica- 
tions upon this subject, he regards catharsis as the main weapon 
with which to combat intestinal putrefaction. 



200 DISEASES OF THE INTESTINES 

A second scarcely less important means of mechanically com- 
batting the causes and results of intestinal putrefaction is careful, 
systematic intestinal lavage. It is well known, and we, too, have 
repeatedly pointed out, that decomposition takes place mainly in the 
large intestine ; the utility of careful and repeated intestinal lavage 
is therefore very apparent. By this procedure we do not attempt to 
sterilize the intestine, nor do we thereby make it impossible for new 
microbes to develop, but we obtain at least a relatively clean con- 
dition of the organ. Intestinal lavage is beneficial also from an- 
other standpoint : a portion of the water is absorbed, causes an 
increase in the excretion of urine, and thus, as Sahli was the first 
to show, numerous products of decomposition are washed out of the 
system. 

For intestinal lavage a number of antiferrnentative substances 
may be added to the water : salicylic acid, boracic acid, resorcin, 
creolin, lysol, creosote, ichthyol, tannic acid, and perhaps also for- 
maldehyde and its preparations (amyloform, dextroform, paraform, 
tannoform, etc.). Yery little has been published regarding the 
last-named preparations. Undoubtedly disinfection of the intestine 
is best accomplished by means of lavage. As regards the technic, 
the only point to be remembered is that the irrigation must be con- 
tinued until the water returns clear. As in gastric lavage, so after 
apparent cleansing of the intestines, a change in the position of 
the body will often cause fresh faecal masses to appear and be 
washed away. 

In spite of the numerous remedies which have been recom- 
mended and tried within the last decade, no important results have 
been obtained for the disinfection of the intestinal canal by way of 
the stomach. Nevertheless, it seems to me that Albu goes too far 
when he says that internal antisepsis, in the broadest sense of the 
word, is an unsolvable problem. The solution certainly will not 
be found in a chemical agent, but rather in a proper selection and 
preparation of the ingested food. In the future, therefore, it should 
be our duty to study more closely than heretofore the effects of the 
various foodstuffs upon decomposition processes in normal and 
abnormal conditions. We must cease to place any value upon 
methods for the estimation of proteid decomposition from the 
amount of ethereal sulphuric acid found, or upon the relation be- 
tween preformed and total sulphuric acid. This method has led to 
the utmost confusion. 

After what has just been said, it will be unnecessary to enumer- 



MEDICINAL TREATMENT OF INTESTINAL DISEASES 201 

ate and discuss the numerous intestinal antiseptics which have been 
recommended. A few of them, however (salol, orphol, nosophen, 
bismuth salicylate, etc.), have, as already mentioned, a distinct 
value in the treatment of chronic diarrhoea. This subject will be 
treated of in detail in the chapter on Diarrhoea, in the second 
part of this work. 

LITERATURE 

1. Aubert. Zeitschr. f. rationelle Medicin, 1852. 

2. Moreau. Memoires de Physiologie. Paris, 1877. 

3. Radziejewski. Arch. f. Anat. u. Physiol., 1870, S. 37. 

4. Brieger. Archiv. f. experiment. Pathol, u. Pharmacol., Bd. viii, S. 335. 

5. Nothnagel. Virchow's Archiv, Bd. lxxxviii, 1884 ; and Beitrage zur Phys- 

iol, u. Pathol, des Darms, 1884. 

6. Jacobj. Archiv f. experiment. Pathol, u. Pharmacol., Bd. xxix, 1891. 

7. Pohl. Ibid., Bd. xxiv, Heft 1 u. 2, 1894. 

8. von Vamossy. Deutsche med. Wochenschr., 1897, No. 29. 

9. Ramm. Ueber Bittermittel. Robert's histor. Studien II, S. 1, cited from 

Virchow-Hirsch Jahresber., 1890, Bd. i, S. 442. 

10. Subbotin. Deutsch. Arch. f. klin. Med., 1869, Bd. vi, S. 285. 

11. Schaefer. Berliner klin. Wochenschr., 1880, No. 51. 

12. Bardet. Comptes rendus de la Societe de therapeutique, 1895. 

13. Rovighi. Zeitschr. f. physiolog. Chemie, Bd. xvi. 

14. Schmitz. Ibid., Bd. xix, S. 378. 

15. Winternitz. Ibid., Bd. xvi. 

16. Albu. Deutsche med. Wochenschr., 1897. No. 32. 

17. Ibid. Loc. cit. and Berliner klin. Wochenschr., 1895, S. 9. 



PART II 
SPECIAL DIVISION 



CHAPTEK XIII 

ACUTE AND CHRONIC INTESTINAL CATARRH 

(Enteritis acuta et chronica) 

1. Acute Intestinal Catarrh 

Preliminary Remarks. — Acute intestinal catarrh owes its im- 
portance not so much to the gravity of its symptoms as to the 
frequency of its occurrence. It affects persons at all ages, more 
particularly, and to a very dangerous degree, children during the 
first two years of life. There is no difference as regards sex. Cer- 
tain periodic variations, dependent upon atmospheric and climatic 
influences, exist. 

The causes of acute enteritis, as of acute catarrhal gastritis, are 
very numerous. Its various forms, however, may, on the whole, be 
traced to the following four primary causes : 

(1) To infection (infectious catarrhs). 

(2) To injurious substances in the ingested food (alimentary or 

ingestive catarrhs). 

(3) To cold (refrigeration catarrhs). 

(4) To the action of medicines or poisons (medicinal or toxic 

catarrhs). 

Infectious catarrhs, according to our present knowledge, are due 
to bacteria or to their metabolic products. The sole primary mani- 
festation of the disease may here be limited to the intestinal canal, 
or the intestinal catarrh may form the chief or accompanying symp- 
tom, or be a complication of other acute infectious diseases (typhoid, 
cholera nostras et asiatica, pneumonia, malaria, anthrax, influenza, 
sepsis, etc.). 

We are here concerned only with the first-named variety. A 
priori, it seems probable that in infectious catarrhs a specific bac- 
terial flora does not exist, and, despite manifold studies in that 
direction, the demonstration of a specific micro-organism as the 
cause of intestinal catarrh has been only partially successful. In 
this connection we would mention Gaffky's 1 demonstration of the 

205 



206 DISEASES OF THE INTESTINES 

bacillus enteritidis (probably identical with the bacterium coli) in a 
severe case of infectious intestinal catarrh. An important though 
not necessarily the sole factor in the etiology of acute enteritis is 
the bacterium coli. 

Alimentary enteritis is the most common form met with. 
Decomposed food, or else wholesome nourishment ingested in 
improper combination or in excessive quantities or of unsuitable 
physical character, may give rise to violent intestinal disturbances, 
which assume the character of an acute intestinal catarrh. Among 
the foods which most frequently excite intestinal catarrh are water, 
ice, milk and its products (butter, cheese, whey), meat and its deriv- 
atives, sausages, fish, fruit, etc. It has been justly assumed that 
poisonous organic bases (ptomains) play an essential part in these 
cases. Some of these have already been determined (Vaughan's 
tyrotoxicon, Firth's lactotoxin, and the ptomains muscarin, guani- 
din, methylguanidin, dimethylamin, methylamin, sethylamin, beta- 
lin, mytilotoxin, etc., isolated by Brieger). In consequence of 
improper combination or excessive ingestion of otherwise whole- 
some food, injurious products of fermentation (lactic, butyric, pro- 
pionic, acetic, caproic, formic, succinic acids, etc.) may be formed, 
which, innocuous in ordinary quantities, may under the above- 
named condition cause violent irritation of the intestinal canal. 

Undoubtedly we also meet with diarrhoeas due to exposure to 
cold, in which, perhaps owing to reflex vaso-motor influences, a 
marked stimulation of the excito-motor nerves is produced. When 
the irritation is violent or the patient careless, an acute intestinal 
catarrh may follow. 

Finally, intestinal catarrh may result from the action of drugs, 
either through the use of abnormally large single doses or from 
the long-continued use of small amounts. Among these are the 
mercurial preparations (calomel, corrosive sublimate), arsenic, anti- 
mony ; the emetics — tartar emetic, ipecacuanha, sulphate of copper, 
apomorphin; the strong drastic purgatives (croton oil, colocynth, 
senna, jalap, gamboge, etc.). Many other medicinal agents, admin- 
istered in unsuitable manner or dosage, may produce intestinal 
catarrh; those named above, however, are the most frequent 
offenders. 

As rare causes of acute enteritis we may mention traumatism, 
the presence of numerous entozoa, and acute coprostasis. 



ACUTE AND CHRONIC INTESTINAL CATARRH 207 

Symptomatology and Diagnosis 

The following description relates solely to acute primary intes- 
tinal catarrh ; all secondary varieties of enteritis — e. g., those that 
occur in the course of typhoid fever, cholera, tuberculosis, malaria, 
pneumonia, etc., carcinoma of the intestines, congestion of the por- 
tal circulation, intestinal ulcerations, intestinal strictures, entozoa, 
etc. — will not here be considered, because foreign to the present 
discussion. As regards the intensity and extension of the process, 
the symptomatology of acute enteritis presents a variety of gradu- 
ated stages, so that it is difficult to faithfully describe all grades and 
forms of the disease. The following description applies to a moder- 
ately severe case of enterocolitis. Of especial importance are : 

1. The commencement of the process. 

2. The gastro -intestinal disturbances. 

3. The patient's general condition. 

4. The course of the disease. 

Certain other symptoms, which will be discussed below, may 
complete the clinical picture. 

As a rule, the symptoms appear suddenly and without prodrom- 
ata, almost immediately following the exciting cause. Tormenting, 
dragging, and boring pains are felt in the abdomen, usually accom- 
panied by general discomfort, nausea, and occasionally even by 
attempts at vomiting. Diarrhoea soon develops. The number and 
character of the evacuations vary according to the localization, 
intensity, and etiology of the disease. Thus in very mild cases 
there may be two to three, in severe cases fifteen to twenty or 
more passages. The first evacuations may still be solid or pasty, 
but the more numerous they become the more fluid and odour- 
less will they be. Should the catarrh involve the upper portions of 
the small intestine, we may recognize its site from the greenish- 
yellow colour of the dejecta and from the presence of unchanged 
bile pigments (Grmelin's reaction). If the catarrh is limited to the 
large intestine this test can no longer be employed, since the bili- 
rubin has already been converted into urobilin. 

All the stools of acute enteritis contain an admixture of mucus, 
partly in the form of exceedingly small, barely visible gelatinous 
particles or minute specks intimately mixed with the stool, partly 
in the form of isolated masses which consist of small or large shreds. 
Besides mucus, blood is not infrequently present, partly as small 
streaks usually adherent to the particles of mucus, partly in the form 



208 DISEASES OF THE INTESTINES 

of larger bright red or coagulated masses, also generally mixed with 
the latter. In my experience copious hemorrhage is very rare 
in acute enteritis. In the majority of cases of uncomplicated 
enteritis, unlike those of dysentery, pus is not present in the evac 
uations. Owing to the active gas formation within the intestines 
the f seces may present a marked frothy appearance. Besides mucus 
the microscopical picture reveals red and white blood-corpuscles, 
and frequently partly fresh but mostly disintegrated epithelium 
We also find various kinds of food remnants, particles of casein 
muscle fibres, starch granules, remnants of cellulose, and other acci- 
dental constituents of food. 

Gastric digestion is frequently interfered with along with the 
intestinal disturbance. The appetite is generally absent, direct 
aversion to food is occasionally present ; in other cases, gastric dis- 
turbances — nausea, vomiting, epigastric pressure — are so prominent 
that the case resembles one of acute gastritis. The tongue is 
usually coated ; a disgusting fetor is present ; thirst is frequently 
tormenting. There is an inverse relation between the number of 
stools and the thirst on the one haud, and the urinary secretion on 
the other. 

The general condition depends essentially on the severity of the 
enteritis and the number of evacuations. Only in very few cases 
does it remain undisturbed ; in the greater number of cases the 
patient complains of considerable lassitude, which in children, in 
the aged, or in otherwise weakened individuals not infrequently 
develops into symptoms of grave prostration. Under these circum- 
stances, a condition of acute hydrocephalus, as described by Marshall 
Hall, may supervene, due to the copious intestinal discharges and 
the resulting cerebral angemia. 

In the vast majority of cases, especially in adults, the disease 
runs a favourable course and is of relatively short duration. Never- 
theless, we occasionally observe, especially in colitis, quite severe 
and protracted forms, in which convalescence is long delayed. 
Other cases are characterized by a persistent vulnerability of the 
intestine, so that under predisposing conditions relapses frequently 
occur ; the process does not go on to perfect recovery, a chronic 
enteritis gradually develops, or a more or less intractable atony of 
the large intestine, accompanied by constipation, remains. 

Certain complicating conditions may be added to this typical 
picture. The disease, which usually runs an afebrile course, may 
be accompanied by more or less severe fever, so as to awaken the 



ACUTE AND CHRONIC INTESTINAL CATARRH 209 

suspicion of a beginning typhoid, tlie more so as enlargement of 
the spleen is occasionally observed. The urine is generally con- 
centrated and dark ; in rare instances anuria may develop. It 
has been observed by various authors, first by Kjellberg 2 and soon 
after by Hermann 3 and Muhlhauser 4 , that albuminuria may oc- 
cur in cholera diarrhoeas ; and Kobler 5 has recently reported two 
cases of cholera nostras, in which for a long time there was a 
marked diminution of urine with albumin and large quantities 
of hyaline and epithelial casts. In one case granular casts and 
renal epithelium could also be demonstrated. Even in the milder 
forms of diarrhoea, as first shown by Fischl 6 and corroborated by 
Stiller 7 , temporary albuminuria and cylindruria may occur. I re- 
cently made the same observation in an elderly patient, in whom 
on the second day of an acute gastro-enteritis I found an appre- 
ciable amount of albumin in his urine (without casts). With the 
improvement of the intestinal catarrh the albuminuria soon dis- 
appeared. 

In exceptional cases in children, according to Turner 8 , fatal 
Bright's disease may follow an acute gastro-enteritis. 

Several authors (Strumpell 9 , Fleischer 10 ) report the occurrence 
of acute pains in the joints and muscles, as well as tumefaction of 
the joints, as a complication of acute enteritis. Herpes labialis has 
also been observed in infectious intestinal catarrh. 

As a rule, the diagnosis of an acute enteritis is not difficult, espe- 
cially where a positive etiological factor (errors in diet, cold, etc.) 
points to the origin of the disease. The diagnosis is based on the 
acute onset, the characteristic gastro -intestinal disturbances, and the 
course of the disease. Compared with these data, the objective 
abdominal symptoms are of subordinate importance. Inspection 
may reveal a slight distention, although this may be absent ; in 
greatly emaciated persons, isolated spasmodic intestinal contractions, 
especially of the small bowel, are occasionally observed. If the colon 
is especially affected, palpation elicits some tenderness on pressure, 
particularly pronounced in the region of the descending colon and 
the sigmoid flexure, and thus may indicate the limits of the inflam- 
mation. In diffuse enteritis, the whole abdomen, especially the cir- 
cumbilical portion, is the seat of more or less decided tenderness. 
No practical data are obtained by percussion. Auscultation enables 
us to hear loud borborygmi and other intestinal sounds even at a 
distance, and better still when the ear is directly applied to the 
abdominal wall. If we except the gastro -duodenal catarrh accom- 



210 DISEASES OF THE INTESTINES 

parried by jaundice which will be considered later, the localization 
is more difficult than the diagnosis of the diseased process. In my 
opinion, the only determination of some practical value is whether 
the seat of the catarrh is in the large or small intestines. The 
absence of large appreciable masses of mucus and blood from the 
stools and the presence of unconverted bile pigment is diagnostic 
of catarrh of the small intestine, while, conversely, the presence of 
a larger quantity of mucus and blood in the faeces argues in favour 
of disease of the colon. If we go still further, and attempt to localize 
the catarrh in the different intestinal segments, we are no longer 
treading upon scientific ground. 

In view of the symptoms above mentioned we will meet with 
diagnostic difficulties only in exceptionally complicated cases. Thus, 
for example, during the first days of febrile gastro- enteritis the 
differentiation from typhoid, as already stated, may be exceedingly 
difficult, and may only become possible after careful observation 
of the course of the disease. This same difficulty confronts us in 
cholera asiatica, particularly when that disease is epidemic. In both 
instances the bacteriological and the serum examination (Widal's 
reaction) may materially assist the formation of a diagnosis. 

The diagnosis of duodenal catarrh conforms completely with 
that of acute and subacute gastric catarrh, and only becomes possi- 
ble with the onset of catarrhal jaundice. Its symptom-complex is 
generally so pronounced that a special description seems superfluous. 

In my opinion, the differential diagnosis between acute colitis and 
the milder forms of dysentery is exceedingly difficult ; I believe that 
we are as yet unable to satisfactorily discriminate between these two 
diseases.* In pronounced cases, and particularly during epidemics, 
the diagnosis is probably less difficult. In dysentery, the presence of 
" [specific bacteria (Shiga, Flexner) or] " the amoeba coli (Loesch) 
in the faeces and in the pus of the liver abscesses is of diagnostic 
importance. 

The treatment of acute intestinal catarrh is based upon the fol- 
lowing principles : 

1. The removal of noxious material from the intestinal canal 

(indicatio causalis). 

2. The greatest possible protection of the gastro-intestinal canal 

(indicatio symptomatica). 

* That this same difficulty has been encountered by other authors is obvious 
from the fact that in literature we not infrequently meet with the designation 
" dysenteroid intestinal catarrh." 



ACUTE AND CHRONIC INTESTINAL CATARRH 211 

We are not always able to carry out the first rule, since only in 
a certain proportion of cases are the noxious materials of a sub- 
stantial nature. Where this indication can be fulfilled, recovery, as 
a rule, immediately follows the removal of the undigested masses. 
Frequently this result is also brought about by the products of 
decomposition themselves, which accumulate in the intestinal canal 
and excite increased peristalsis. Further treatment is then hardly 
necessary. Where, however, in spite of the obvious presence of 
noxious material, the evacuations are arrested or insufficient, the 
removal of this material by a suitable purge is of primary impor- 
tance. For this purpose, calomel (0.2 to 0.3 grams, every three 
hours) [until the desired effect is obtained] or castor oil (in doses of 
one to two tablespoonfuls) is preferable. 

Since the early days of medicine it has been customary to give 
calomel preferably in "infectious" catarrhs, and castor oil in cases 
due simply to errors in diet ; still, the superiority of the one over 
the other is by no means established. In my opinion, both act as 
disinfectants by rapidly and thoroughly emptying the bowels. 

The second indication — protection of the gastro-intestinal canal 
— must be considered after the first has been fulfilled, or where, 
owing to the absence of recognisable etiological factors, this is unat- 
tainable. This second indication is principally fulfilled by complete 
rest in bed for several days, by constant and uniform application to 
the abdomen of heat in the shape of warm fomentations, and most 
especially by a proper diet. For the first two or three days the 
diet should consist of fluids only. All liquids, however, are not 
suitable ; for example, milk is contra-indicated in all forms of acute 
enteritis. Cold drinks as well as carbonated waters should also be 
avoided, excepting when severe vomiting is also present for ex- 
perience has shown that ice and iced drinks tend to check the 
nausea. In acute cases the diet should therefore be limited to the 
following : watery gruels, thin bouillon without salt or spices, tea 
or cocoa made with water alone (no sugar, but in its stead saccha- 
rin), claret with or without water, egg albumen, decoctions of arrow- 
root and hygiama gruels, etc. Carminative teas are also frequently 
useful — e. g., peppermint, valerian, fennel, anise seed, thyme, cara- 
way, marsh mallow, etc. 

Only after the intestine has become absolutely quiescent, and 
tenderness to pressure has disappeared, may we increase the diet by 
adding one or more softened zwiebacks, next permitting the lightest 
forms of meat and fish, with some boiled rice or mashed potatoes, 



212 DISEASES OF THE INTESTINES 

gradually approaching the ordinary diet. The patient should be 
instructed to carefully abstain from excesses in food and drink for 
a number of weeks, to avoid all indigestible, fatty, tough foods, 
and also those rich in cellulose, for, as previously stated, the intes- 
tine is very vulnerable for a long time. 

These measures are all that are required for the cure of a large 
number of cases. It will only exceptionally be found necessary to 
control excessive diarrhoea, or, on the other hand, to combat a reac- 
tive constipation or to stimulate a failing appetite. The first is 
accomplished by the administration of opiates in the form of tinc- 
ture of opium (10 to 15 drops, repeated one to four times) or 
the extract of opium (0.03, repeated two or three times a day), in- 
ternally or in suppositories. I regard the continued administration 
of opiates not only as unnecessary but even as injurious. When, 
as frequently happens, constipation oeeurs after- the diarrhoea 
has subsided, this must not be treated by purgatives, hut only 
by suitable enemata of oU or of soapsuds. The appetite gen- 
erally returns in due course of time. It may be stimulated by 
the well-known stomachics (the fluid extract or decoction of con- 
durango, the tincture of mix vomica, the compound tincture of 
cinchona, etc. . 

In conditions of grave collapse we may endeavour to arouse the 
heart's action by stimulants administered internally (e. g., wine, 
cognac, ether) or subcutaneously (e. g\. oil of camphor, citrate of 
caifein). 

2. Chronic Intestinal Catarrh 

Preliminary Remarks. — Chronic enteritis may result from 
acute intestinal catarrhs in which recovery has taken place only 
incompletely or not at all, or from long-continued and various 
kinds of injuries of the intestinal canal. Among the injurious 
agents which conduce to chronic intestinal catarrh, those which 
directly affect the gastrointestinal mucous membrane are the most 
important and the most frequent. These include improper food, 
frequent colds, abuse of purgatives, constipation, etc. The pri- 
mary forms of enteritis are caused in this manner. As distin- 
guished from these, the secondary forms are those which develop 
either in connection with gastric diseases (e. g.. catarrhs, carcinoma, 
fermentation, etc.) or from intestinal diseases (tumours, ulcerations, 
stenoses, adhesions, displacements, etc.). The intestinal catarrh is 
often overshadowed by the other predominant symptoms, or it 



ACUTE AND CHRONIC INTESTINAL CATARRH 213 

may be so prominent that the etiological factor is only of second- 
ary clinical importance. Nothnagel u correctly remarks that a con- 
gestive enteritis, in the true sense of the word, does not exist ; at 
the most, we may concede that hyperemia of the intestinal tract 
creates conditions favourable to the development of chronic catarrhs. 
As a matter of fact, I believe they occur very rarely as secondary 
catarrhs dependent upon the main disease ; and when they do occur, 
who can prove that they have developed in this way, and are not 
accidental complications ? • 

Clinical observation combined with post-mortem examination 
teaches us that we must distinguish between different grades and 
forms of enteritis, and that these affect various intestinal segments. 
For the better understanding of this I preface my remarks with a 
short description of the pathologico-anatomical changes that are 
found. 

On macroscopical examination of such a diseased bowel the attention is 
immediately arrested by a brown or black pigmentation of the mucous mem- 
brane, which particularly affects the region of the villi and that of the fol- 
licles. Peyer's patches may also present such discolourations, caused by old 
hemorrhages. The histological changes involve chiefly the mucosa; they may 
also involve the submucosa, or the muscularis. The changes may consist of 
a cellular infiltration of the interstitial connective tissue (leucocyte infiltra- 
tion), from which a genuine hypertrophy of the connective tissue may develop 
and this may occur to such a degree that the intestinal lumen becomes nar- 
rowed for quite some distance. In other cases there is a polypoid prolifera- 
tion of the tissues. In still other instances there are cystic dilatations (enteritis 
chronica cystica), produced by strangulation of conglomerations of glands. 
Usually -the cysts are small and hardly visible to the naked eye, but they may 
attain the size of a pin's head or a lentil. Their contents consist of a peculiar 
slimy, viscid fluid, whose clinical nature has not as yet been positively de- 
termined. In contrast to these plastic inflammatory processes a degenerative 
form can also be distinguished. This affects the glands rather than the con- 
nective tissue, destruction and atrophy of the glands gradually occurring as a 
result of the marked epithelial desquamation. At the same time the other 
layers of the mucous membrane generally lose their powers of resistance. The 
mucosa becomes thin and lamellated, the villi atrophied, so that on section we 
are only able to recognise isolated remnants projecting from the general level 
of the mucous membrane. Besides these changes, the process especially affects 
the intestinal follicles, which are swollen at first and are surrounded by a hyper- 
asmic zone ; later they rupture, and thus give rise to so-called follicular (len- 
ticular) ulcers. In addition to these last, other erosions result from desquama- 
tion and loss of epithelium. At first they are superficial, but through their 
confluence and deeper extension true catarrhal ulcerations may gradually be 
formed. 

15 



214 DISEASES OF THE INTESTINES 

Pathological anatomy not only distinguishes between the variety, 
but also between the situations of morbid processes, and hence 
speaks of a duodenitis, jejunitis, ileitis, colitis, and proctitis. 
Clinically, these fine distinctions can not be made, and we must be 
content with a division into catarrh of the small and catarrh of 
the large intestines. 

Since catarrhs of the small and of the large intestines, however, 
frequently coexist, we must also consider this combination clinically. 
In an anatomical sense the one will naturally preponderate over 
the other, while the one intestinal division is extensively diseased, 
only a small portion of the other will be affected. In the present 
state of our knowledge these fine gradations can scarcely be made, 
and in view of the great number of variations met with they are of 
little practical value. The clinical diagnosis, therefore, will have 
to deal mainly with the following two questions : 

1. Is an intestinal catarrh really present ? 

2. Does it involve the small or large intestine alone, or 
both? 

In the following we will first outline the general symptoms of 
intestinal catarrh, and then will consider its localization. 

General Symptomatology and Diagnosis of Chronic 
Intestinal Catarrh 

In chronic intestinal catarrh the clinical picture is mainly formed 
by the subjective symptoms, or by objective abdominal manifesta- 
tions — especially, marked variations in the number and character 
of the stools. 

The subjective symptoms vary greatly in degree. They may 
be absent, or may only manifest themselves by disturbances of def- 
ecation ; they may be only just felt, or may constitute the main 
complaint of the patient; they are constant or periodical, may 
disappear with or without the objective symptoms, or vice versa ; 
they may persist, notwithstanding the cessation of the characteristic 
intestinal symptoms. Daily observation furnishes numerous ex- 
amples of all the variations. We will have to refrain from de- 
scribing them all, since an exhaustive description would not be pos- 
sible. We shall, however, describe a few forms of chronic enteritis 
that are of practical importance. 

In typical cases of chronic intestinal catarrh the symptoms con- 
sist in feelings of discomfort or pressure, pain or soreness in the 
abdomen, combined with intestinal rumbling and hyperperistalsis, 



ACUTE AND CHRONIC INTESTINAL CATARRH 215 

followed usually by copious alvine evacuations. In marked cases 
these symptoms may be constant, or they may occur only in parox- 
ysms — e. g., following a slight cold, excessive mental or bodily exer- 
tion, dietetic errors, mental excitement, etc. The patient at the same 
time has a sense of intense discomfort, of bodily and mental depres- 
sion, to which are sometimes added salivation, retching, or actual 
vomiting. Where the intestinal catarrh is situated very far down, 
painful tenesmus is also present. In atypical or less marked 
cases the symptoms are confined to uncomfortable painful sen- 
sations which involve the whole abdomen, or else are limited 
to certain areas — e. g., the umbilical region or portions of the 
large intestine. When gas or fasces are passed these sensations 
may rapidly disappear. I would call particular attention to the 
frequent occurrence of this form of intestinal catarrh, for I am 
convinced it is only rarely recognised, since it may be accompa- 
nied by apparently normal faecal evacuations. By careful observa- 
tion and questioning of the patient, but especially from an exami- 
nation of the dejecta, we may convince ourselves that these patients 
are affected with a slight or only partially healed intestinal catarrh. 
This will be again referred to in discussing the diagnosis. In 
another form of intestinal catarrh — the coprostatic — the subjective 
symptoms are entirely different. The above-mentioned symptoms 
are either entirely absent, or they appear as periodic intestinal colics, 
with spastic obstipation, or else in the form of a constant or very 
frequent feeling of pressure in the dependent portions of the intes- 
tines, or even as meteorism accompanied by more or less marked 
flatulency. 

Between these two extremes we meet with cases in which the 
first-described combine in the most diverse manner with the last- 
described varieties. 

The general condition of patients suffering from chronic enteri- 
tis varies very markedly. As a rule, it is only slightly altered from 
the normal in constipating enteritis, but very much more so in that 
form accompanied by copious diarrhoea, especially where the upper 
portions of the intestine are principally affected. Occasionally, 
however, we meet with chronic diarrhoeas in which there is no 
deterioration of the general health, while, on the other hand, it is 
not rare to find cases of constipating enteritis in which the bodily 
weight and general condition have been gravely affected. This 
variable behaviour can not in all cases be explained alike. In a 
great number the psychic factor — i. e., the general depression — no 



216 DISEASES OF THE INTESTINES 

doubt exerts an unfavourable influence upon the ingestion of food ; 
in others, again, the loss of fluids is the main cause ; in still others 
an irregular mode of life, errors of diet, excessive bodily or mental 
work, will cause a loss of strength and weight. The longer the dis- 
ease exists and the more frequently curative measures fail to bring 
relief, the sooner will the patient present a certain neurasthenic 
tendency, which may even to the most experienced physician 
obscure the true cause of the malady. 

The objective examination is divided into that of the abdomen 
and that of the dejecta. In the first, palpation alone possesses posi- 
tive value. Percussion and auscultation may perhaps demonstrate 
the existence of meteorism, of accumulated fseces, of abnormally 
increased intestinal sounds, but they do not of themselves permit 
of any conclusions as to the existence, location, or extent of the 
intestinal catarrh. On the other hand, palpation may sometimes 
be of value in determining a tenderness of certain intestinal areas, 
thus, as will be later explained, indicating the seat of the intestinal 
catarrh. The evacuations vary very much, according to the nature 
and seat of the disease. The movements may be tardy, or may 
occur at regular intervals ; they may occur too frequently or in 
excessive amount, or after several days of constipation there may 
suddenly be a single or repeated diarrhceal movement ; or, finally, 
after, a period of days or weeks of perfect health, suddenly, and 
often without any recognisable cause, a normal stool may assume a 
diarrhceal character. 

Of still greater importance are the changes in the composition 
of the faeces, as well as the presence of abnormal admixtures, par- 
ticularly the constant occurrence of mucus. The change in com- 
position may be due to an increased amount of undigested foodstuffs, 
which can sometimes be recognised macroscopically, but better still 
microscopically. 

The presence of mucus is the most frequent and most charac- 
teristic symptom of intestinal catarrh. The amount of mucus 
voided varies greatly, however, according to the seat of the disease ; 
this will again be referred to in the discussion on the localization 
of intestinal catarrh. The presence of mucus in one movement 
does not conclusively prove the existence of an intestinal catarrh, 
neither does its absence exclude the same. The first statement will 
scarcely be denied ; it is important, however, to emphasize the fact 
that severe catarrhal conditions may exist without the production 
of mucus. Thus, since Nothnagel's 12 investigation on this subject, 



ACUTE AND CHRONIC INTESTINAL CATARRH 217 

it has generally been accepted, and I believe with perfect justice, 
that in atrophy of the intestine (which, by the way, frequently 
eludes a positive diagnosis) mucus is entirely absent from the 
dejecta. An admixture of blood is not one of the characteristics 
of primary enteritis ; it, as well as pus, represents only one of the 
complications. 

The course of chronic enteritis is tedious and protracted. 
Undoubtedly a functional cure is sometimes achieved. If we con- 
sider analogous conditions of other organs (the stomach, the urethra, 
the larynx, the uterus), it is at least doubtful whether there are ever 
any cures in an anatomical sense. The following experience, which 
undoubtedly other physicians have also had, is very interesting, 
viz. : after a catarrh lasting for many years, a sudden change in its 
character may occur — i. e., chronic diarrhoea may gradually give 
place to a marked tendency toward constipation, or vice versa. In 
these cases there have been changes in the mechanism of innerva- 
tion, the nature of which is as yet entirely unknown to us. 

If we consider the picture outlined in the foregoing pages, the 
diagnosis of chronic enteritis in marked cases is not especially dif- 
ficult. It is more difficult, however, in atypical cases, and particu- 
larly its differentiation from simple functional diarrhoeas is an 
extremely delicate problem. There is no objective symptom in 
the latter that may not also be present in catarrh. From numer- 
ous personal observations, I can state that mucus, undigested food 
remnants, and bile pigment may be present in nervous diarrhoea as 
in intestinal catarrh. An analysis of such cases shows — and this 
is perhaps the key to the proper understanding of these compli- 
cated conditions — that, in consequence of a continued chemical and 
mechanical irritation of the intestinal mucous membrane, a true 
intestinal catarrh may be developed from a purely functional diar- 
rhoea. For the elucidation of these difficult questions, an exact 
previous history and status prmsens, particularly as to the nervous 
system, are very necessary. We thus learn that the disease occurs 
paroxysmally, that it is frequently increased by psychic excitement 
or mental and bodily fatigue, that during rest it subsides or inter- 
mits, and that also in the latter case an occasional dietetic error is 
borne without injurious results, etc. Objectively, other signs of 
hysteria or neurasthenia may be present : increased reflexes, local 
hyp- or hyperalgesia, autographia, vasomotor disturbances, etc. 

In spite of all these diagnostic auxiliaries, we entirely agree 
with Nothnagel that the diagnosis can frequently be made only 



218 DISEASES OF THE INTESTINES 

ex juvantibus et nocentibus. In discussing nervous diarrhoea, we 
shall again refer to the individual symptoms. 

As indicated above, the abortive or ill-defined cases of intestinal 
catarrh are also of practical interest. These may occur with appar- 
ently normal intestinal evacuations, and manifest themselves by 
occasional painful abdominal sensations. A careful examination of 
the faeces will, however, reveal the characteristic signs of intestinal 
catarrh, now to be described. 

For the diagnosis of intestinal catarrh, aside from the less posi- 
tive data obtained from physical examination of the abdomen, there 
are in reality only two other methods of examination : test lavage of 
the intestine (see page 87) and the examination of the dejecta. 
The first method at once shows whether the large intestine is the 
seat of a chronic irritation attended with hypersecretion of mucus, 
and should for this reason never be omitted in any [suspected] case 
of intestinal catarrh. Under certain circumstances examination of 
the dejecta may decide the diagnosis ; it may show the presence of 
abnormal undigested matter or of certain admixtures (especially 
mucus) as prominent constituents of the faeces. Regarding the 
undigested foodstuffs, we must at present be satisfied with the 
gross differentiation derived from the comparison of the normal 
with the abnormal stool. A positive functional test of the intes- 
tine alone will furnish us with an exact knowledge of the devia- 
tions from the normal. 

For the examination of mucus and other abnormal constituents, 
see above, page 96 et seq. 

Diagnosis of Catarrh of the Small Intestine 

The main symptom of catarrh of the small intestine is the 
anomalous condition of the faeces. The subjective symptoms pre- 
viously mentioned are also of some value. 

With the exception of the dejecta (soon to be described), the 
most important, at times the most diagnostic objective symptom, is 
the presence of a well-defined pressure sensitiveness. In my 
experience, catarrh of the small intestine may sometimes, at first 
sight, be differentiated from that of the large intestine by this 
means. While objective tenderness is either entirely absent in the 
former, or, when present, is usually elicited only in the mesogas- 
trium above or below the umbilicus (especially in tuberculous diar- 
rhoea), diffuse tenderness on pressure is frequently found, in chronic 
catarrh of the large bowel; although rare in the region of the 



ACUTE AND CHRONIC INTESTINAL CATARRH 219 

caecum, it is well-pronounced over the sigmoid flexure and descend- 
ing colon. 

In these cases the evacuations are usually diarrhoeal. But, as 
Kothnagel has conclusively shown, they may be semisolid or even 
quite firm. Where they are fluid or semifluid, the admixture of 
mucous shreds, as well as the presence of bile pigment and of bile- 
tinged epithelial cells and muscular fibres, indicate an affection of 
the small intestine. Where the evacuations are firm, the question 
of disease of the small or of the large intestine is most readily and 
positively answered by means of a test lavage of the bowel. If the 
irrigation repeatedly brings away large quantities of membranous or 
viscid mucus, there is undoubtedly a catarrh of the large intestine 
present ; whether catarrh of the small intestine coexists can not be 
determined by this procedure. If the test lavage results nega- 
tively, the diagnosis is very difficult in case the stool is firm or 
semisolid, J^othnagel has stated that the presence of so-called 
yellow mucous granules or of hyaline mucous islets is characteris- 
tic of catarrh of the small intestine, or of catarrh of the upper- 
most portion of the large intestine (page 96). The existence of 
these formations has, however, been denied by Ad. Schmidt, whose 
opinion I must corroborate on the ground of numerous personal 
examinations of faeces. 

It will thus be seen that, aside from the subjective symptoms, 
which are for the most part uncharacteristic, the diagnosis of that 
form of catarrh of the small intestine which is accompanied by 
constipation or by normal dejecta, rests upon the demonstration of 
abnormal products — i. e., unchanged bile pigment (demonstrable 
either macro- or microscopically), the constant presence of exceed- 
ingly numerous muscular fibres, of well-developed starch cells, of 
fat in the form of globules or needles (fatty acids or fatty soaps) in 
the faeces. 

As has been previously remarked, the localization of a catarrh 
of the small intestines (duodenum, jejunum, ileum) is very difficult, 
and usually impossible. Nevertheless, according to my experience, 
we occasionally meet with cases in which the diagnosis may be ven- 
tured. The following case is an illustration : 

EmilB., sixty-two years of age, cabinetmaker, has always been perfectly 
healthy. He was taken ill in the summer of 1892 with a feeling of pressure in 
the epigastrium and violent diarrhoea (about seventeen evacuations in twenty- 
four hours). From October, 1892, to March, 1893, his condition improved. At 
this time there was a recurrence of his diarrhoea (four liquid stools a day), to- 



220 DISEASES OF THE INTESTINES 

gether with painful sensation of pressure in the region of the stomach. The 
patient complained also of shortness of breath and bodily weakness. His con- 
dition, as recorded at the time, was as follows : Examination of the abdomen, 
negative ; lungs emphysematous ; diffuse bronchitis ; heart dulness partially 
obscured by the lungs ; cardiac sounds clear. Test lavage of the intestine 
yielded numerous large shreds of mucus. Microscopic examination of fasces 
negative. Treatment dietetic. Improvement. On July 18, 1895, the patient 
returned, complaining again of diarrhoea. The first stool in the morning is the 
only one of a somewhat firm consistency; the others (six to ten) are always 
fluid. After the principal meal there are always two to three stools at short 
intervals. No pain or tenesmus is present ; rumbling of the bowels is felt. 
The appetite is fair ; there are no eructations, no vomiting ; the diarrhoea is said 
to be unaffected by the kind of nourishment taken. 

Condition on July 18, 1895. The patient is a well-nourished man, with 
a normal colour of the skin. The mucous membranes are somewhat pale. The 
lungs are emphysematous. The area of cardiac dulness is somewhat dimin- 
ished ; heart sounds are clear, though somewhat muffled. The radial artery 
rigid. The abdomen is well rounded, the abdominal muscles tense. There is 
no tumour present, no tenderness, no splashing sounds, oedema, or eruptions of 
the skin. The urine is free from albumin and sugar, but contains indican in 
moderate amount. 

The dejections are fluid, of a brownish-yellow colour ; their odour is pun- 
gently acid, but not at all fsecal. Reaction, decidedly acid. They give a posi- 
tive reaction for bile pigment. A digestive test was made with a filtrate of the 
stool, by means of a scale of albumin (serum albumin), without any further addi- 
tion. At the expiration of three and a half hours the albumin scale was per- 
fectly dissolved. 

Microscopical examination showed little mucus, much starch in well-pre- 
served granules, many muscular fibres, strongly tinged with bile. Examina- 
tion of further specimens of fasces, gave the same result, excepting that the 
digestive test (with albumin) was negative. Test lavage of the large intestine 
yielded jellylike mucus. 

My opinion that this case was one of catarrh of the npper por- 
tion of the small intestine (with probable catarrh of the colon) is 
based upon the pronounced biliary character of the brownish-yellow 
fluid evacuations, which were quite free from fsecal admixture. 
Although the digestion test only gave positive results on a single 
occasion — something very unusual in my experience — yet this, when 
taken in connection with the other features of the case, serves as an 
additional support to the diagnosis. As far as I have seen, Noth- 
nagel 12 is the only one who has called attention to the peculiarities 
of the stools in such cases, and to the difficulties of a differential 
diagnosis between these diarrhoeas (jejunal diarrhoea) and the true 
catarrhs. 

Special mention should be made of a form of dyspeptic diarrhoea 



ACUTE AND CHRONIC INTESTINAL CATARRH 221 

which I have frequently met with, and which is of extreme prac- 
tical importance. It is associated with severe types of chronic 
gastric catarrh, such as, following the nomenclature of Einhorn, 
are now called achylia gastrica. Biedert 13 published minute and 
valuable personal observations, and subsequently Einhorn 14 , and 
especially Oppler 15 , have called attention to this condition. It is 
characterized by a subsidence of the subjective gastric symptoms 
and the appearance of chronic intestinal disorders, severe diarrhoea 
being especially complained of. As a rule, while the motor func- 
tion remains intact, the gastric secretion completely disappears. 
Examination of the stools shows a disturbance in digestion, abun- 
dant unaltered food residues, remains of animal tissues, espe- 
cially connective tissue, vegetable products, and also, but less often, 
fatty elements are present. Of the numerous observations of this 
sort which I have collected in the course of years I will quote 
but one, and that notable for the extent of the functional disturb- 
ances. 

Max G-. , nurse, forty-one years old. Underwent an operation for hemor- 
rhoids six years ago, after which — doubtless because of a stricture of the rectum 
— rectal bougies were passed for several weeks. From that time until two years 
ago the patient remained well ; then he began to have occasional attacks of 
diarrhoea. The patient denies any, even slight, gastric symptoms at this period, 
excepting perhaps acid eructations. At all events, he could eat any kind of 
food without discomfort. In the last two months the diarrhoea has mark- 
edly increased, so that he now has four or five thin fluid movements each day, 
without tenesmus. 

Examination of the abdomen and rectum is quite negative. On the other 
hand, repeated examination of the gastric contents shows absolutely undigested 
food with a good deal of mucus, and neither free nor combined hydrochloric 
acid. Examination for pepsin gives negative results; that for rennet ferment 
shows that only when undiluted is the gastric juice capable of coagulating 
milk. In order to ascertain the digestive capacity of the intestine, the patient 
was given a test meal on the evening of December 19, 1898, consisting of a 
quarter of a pound of uncooked beef cut into small pieces. On the following 
morning the faeces consisted almost exclusively of undigested meat, particularly 
the connective tissue. 

At a second test, in which the same quantity of beef was given in minced 
form, numerous undigested fragments of connective tissue were again found, 
and on microscopic examination a moderate quantity of muscular fibres. This 
stool was a thin fluid of brownish colour; its filtrate gave a flocculent precipi- 
tate with nitric acid, and with caustic potash and sulphate of copper (in very 
dilute solution) a decided biuret reaction. The examination was repeated on 
several occasions with the same result, except that the biuret reaction varied in 
intensitv. 



222 DISEASES OF THE INTESTINES 

This case is therefore one of those which the older writers used 
to call lientery (Xelov, slippery, and evrepov, bowels). It would be 
difficult to decide in this case whether we have to deal with a true 
enteritis or with a partial atrophy, but doubtless a marked functional 
disturbance in the secretion of the intestinal glands and the pancreas 
must be thought of. The latter feature has acquired special inter- 
est from the fact, long since known, but recently confirmed by 
Pawlow 16 (who has demonstrated it in a way worthy of imitation by 
other investigators), that the hydrochloric acid of the gastric juice 
is the most important excitor of pancreatic secretion. Thus, if we 
may transfer the results of animal experiments to human physi- 
ology, a new light is shed upon the origin of this form of intestinal 
dyspepsia. 

Diagnosis of Chronic Catarrh of the Large Intestine 

In well-marked cases the diagnosis of uncomplicated catarrh of 
the large intestine seldom offers difficulties. The subjective signs 
are essentially those which depend on the function of defecation, 
and are not characteristic, unless it may be the tormenting feeling 
of pressure or pain, above mentioned, or, in diarrhceal cases, the 
colicky pains, to which tenesmus may be added, if the process ex- 
tends to the lower segments of the bowel. 

The objective signs consist in tenderness on pressure and changes 
in the fseces. The tenderness on pressure, which has already been 
described, is by no means constant. When present, it seldom 
extends over the entire length of the large intestine, but affects 
localized segments, most frequently the descending colon and sig- 
moid flexure. The sensitiveness may be of various degrees of 
intensity ; occasionally even the slightest pressure is disagreeable. 
Patients with well-marked tenderness usually complain of pain in 
the corresponding portion of the bowel, particularly after being 
seated for a long time, or after walking, bending, or riding, etc. 

The nature and form of the mucus evacuations is of great impor- 
tance in determining the regional extension of catarrh of the large 
intestine. The lower the portion affected, the purer and more 
unmixed are the mucus dejections. Thus the passage of pure 
mucus points to catarrh of the rectum, the sigmoid flexure, or the 
lower segment of the descending colon. Similarly, hard masses of 
faeces coated with mucus indicate that the disease is situated in the 
lower portions of the bowel. 

The examination of the stools gives the following results : 



ACUTE AND CHRONIC INTESTINAL CATARRH 223 

(a) With Constipation. — The stools frequently show mucus 
either gelatinous or in strips (membranes), but not so constantly as 
after irrigation. In other respects the formation may be normal or 
diarrhoeal, or of the consistence of pulp, or like sheep dung. For 
the microscopical peculiarities, see chapter on the Examination of 
the Faeces. 

(h) With Diarrhoea. — In these cases the diagnosis as to localiza- 
tion is best reached by exclusion — that is to say, by observing the 
absence of unchanged biliary pigment. In other respects the stools 
in this, as well as in the previously described form, show only scanty 
food residues, in particular very little unchanged muscular fibre, 
starch, or fat. The mucus is usually found intimately mingled 
with the stool, or in the form of little shreds visible when the vessel 
is rotated. 

Diagnosis of Mixed Forms of Intestinal Catarrh 

The diagnosis can be made solely from the peculiarity of the 
stools, which in such cases are almost always diarrhoeal. As before, 
the recognition of biliary pigment, undigested food residues, espe- 
cially muscular fibres, points to a localization in the small intestine, 
while the results of irrigation will show whether or not the large 
intestine is involved. The character of the stools as regards mucus 
resembles that of catarrh of the large intestine. 

Although in the preceding pages we have described the clinical 
characteristics of intestinal catarrh with especial reference to the 
determination of the regional extent as fully as our present knowl- 
edge permits, we must not forget that such a delineation is largely 
schematic. When we consider that hypertrophic catarrhal pro- 
cesses are frequently associated with atrophic changes that can 
not be diagnosticated, that catarrhs may arise from neurotic con- 
ditions, that disturbances in intestinal absorption must be con- 
sidered and may markedly influence the clinical picture, we must 
exercise the greatest caution in expressing an opinion in those 
cases where the existing conditions permit of more than one 
interpretation. 

Treatment of Chronic Enteritis 

In the treatment of primary chronic intestinal catarrh, as in all 
catarrhs of mucous membranes, the same principle that we have 
insisted upon in acute enteritis holds good : Protection of the dis- 
eased organ. 



224 DISEASES OF THE INTESTINES 

Especially must the nature, the seat, and the extent of the 
underlying disease be considered in this connection. In the absence 
of better criteria the character of the stools will serve as an indi- 
cator, in all essential features, of the morbid processes going on 
within the intestine. 

For all practical purposes we are called upon to treat but three 
conditions : Diarrhoea, constipation, and constipation alternating 
with diarrhoea. 

1. Diarrhoea 

The most important part of the treatment is to insure complete 
bodily rest and protection. In the milder cases, moderate physical 
exertion or intellectual work may be permitted, but in the severer 
forms these should be absolutely prohibited. Such patients should 
be put to bed and kept there for at least several weeks. 

Absolute rest in bed has the advantage that, once for all, it puts 
a stop to the external influences so often conspicuous in chronic 
diarrhoea, namely, cold, wet, mental or physical exertion, and, above 
all, dietetic excesses or transgressions. As the other diagnostic 
and therapeutic procedures are difficult to carry out at home, the 
treatment — especially of advanced cases — is best conducted in hos- 
pitals or in private sanitaria, in which dietetic arrangements are 
well managed. 

During the stay in bed, continuous warm fomentations may be 
used with advantage. An appropriate diet is absolutely essential. 
There are three points to be observed : 1. To avoid injurious sub- 
stances which might increase the intestinal catarrh. 2. To select 
such nutrients as will be assimilated in the particular case. 3. To 
combine the greatest variety of those nutrients whose physiological 
action is astringent or which reduce secretion — in other words, those 
which have a tendency to constipate. 

The details of such a diet have been given in extenso in the 
General Section (page 149). For those physicians who have had 
little experience in prescribing a special dietary, the following may 
be of assistance : 

8 a. m. — " Eichel cocoa " (in water), one saccharin tablet (or 
crystallose), toast and butter (20 to 30 grams). 
10 a. m. — One cup (200 grams) rice gruel, buckwheat or oat grits 
in veal bouillon (avoid salt). In addition, 50 grams 
roasted veal or beef (scraped), or fried fish or cold 
meat (avoid salt or strongly pickled ham). 



ACUTE AND CHRONIC INTESTINAL CATARRH 225 

1 p. m. — Soup of peas or beans or puree of oatmeal, farina, or 
corn starch, etc. (addition of nutrose, tropon, or eucasin 
allowed ; somatose forbidden). In summer, huckleberry 
soup (with saccharin, if desired). Two hundred grams 
of rice bouillon (avoid rice with milk),* or farina bou- 
illon, well thickened by cooking. 

Green vegetables or potatoes in puree form (50 to 
100 grams). 

Meat and fish (fat excepted), 50 to 100 grams. 
(Butter sauce allowed ; cream sauces or highly seasoned 
sauces forbidden.) 

Stewed fruits, with the exception of huckleberries 
and cranberries, forbidden. 

Custards (corn starch, with a little yolk of egg and 
saccharin) allowed. (Avoid fruit juices.) 

As beverages : Huckleberry wine, Burgundy, Cama- 
rite, Simaruba wine, old Bordeaux. (Sweet wines, white 
wines, and effervescent beverages forbidden.) 
4 p. m. — Tea (without milk), with saccharin or cocoa. Cakes, 

toast, zwieback (with butter). 
7 p. m. — Strained gruel (oatmeal, etc.). Cold or warm meat 
(50 grams), toast, butter (20 grams). 

One or two glasses of huckleberry wine. 

9 p. m. — One glass of huckleberry lemonade, f warm, or hot 

mulled wine (saccharin), or tea, with red wine. 

It may be necessary to cut out many articles from this dietary. 
It should only be relaxed when the general and local conditions are 
satisfactory, and the stools have been formed for at least four 
weeks without any relapses having occurred. 

Sugar, pastry, milk, organic aeids, salt, beer, effervescing bev- 
erages, cold drinks, and fruit ices shcndd be positively avoided for 
months, and in many cases for years. 

The value of such a diet, taken in connection with absolute rest 
in bed, can not be overestimated. Indeed, I know of nothing 
which can replace this treatment. Nevertheless, in some cases the 
use of medicines will be required. 

Medicinal Treatment. — We know of no drag which will care 

* As to avoiding milk, see page 144. 

f Huckleberry lemonade is made by adding one or two teaspoonfuls of huckle- 
berry jelly to boiled water. 



226 DISEASES OF THE INTESTINES 

an intestinal catarrh; hat one of the symptoms, diarrhoea, may 
sometimes be favourably influenced by appropriate medication. 

There is nothing to add to what has been said in the General Sec- 
tion (page 149 et seq.). We can only repeat that we have little faith 
in the value of the numerous astringent and antiseptic remedies 
which have recently come to notice. Yet there is one drug that 
should not be forgotten, because it combines a certain degree of util- 
ity with the absence of any objectionable feature. I refer to chalk. 
It should be given as a mixture of equal parts of carbonate of 
lime and phosphate of lime. For several years I have preferred to 
treat cases in which diarrhoea has persisted in spite of dietary regu- 
lation, by giving a teaspoonful of this powder three times a day. 

Jaworski 17 has recently recommended chalk dissolved in carbon- 
ated water for diarrhceal cases. He uses two formulae, a stronger 
and a weaker, as follows : 

5 Calcii carbon 2.0 

Calcii salicyl 2.0 

Dissolved in one litre of highly charged carbonic water. (Aq. 
calcii mitior.) 

^ Calcii carbon 4.0 

Calcii salicyl 3.0 

In similar solution. (Aq. calcii fortior.) 

One half a glass of the stronger is to be taken fasting, in the 
morning, and a half glass of the weaker, three times a day, after 
meals. In severe cases Jaworski recommends that the above be 
taken mixed with a half glass of warm Carlsbad Sprudel water. 

The use of preparations of chalk is specially valuable when there 
are eructations of hydrochloric acid, for here the sodium prepara- 
tions are contra - indicated on account of their laxative tendency. 
A combination of the above - mentioned chalk mixture with bis- 
muth has been highly recommended. I prefer the beta-naphtholate 
(orphol). The following formula is unobjectionable and appro- 
priate : 

^ Calcii carbon. 

Calcii phosph., aa 25.0 

Bismuthi beta-naphthol 5.0 

M. One teaspoonful three times a day. 

Besides the preparations of lime just mentioned, the natural 
mineral waters containing lime are useful as adjuvants [see 



ACUTE AND CHRONIC INTESTINAL CATARRH 227 

pp. 163 and 161]. They are especially suitable as table beverages. 
I have often ordered them (warm, one glass morning and evening) 
with good results, and can heartily recommend this treatment.* 

Concerning the other hydrotherapeutic methods, see General 
Section, page 158 et seq. 

For the functional diarrhoeas that occur with achylia gastrica, 
Oppler 15 has found hydrochloric acid in large doses (20 to 30 drops, 
and even more) very satisfactory. 

If there are gastric disorders, and especially loss of appetite with 
chronic intestinal catarrh, I particularly recommend the use of 
wine of calumbo (a dessert glassful three times a day, before 
meals), or the fluid extract of calumbo (a teaspoonful three times 
a day, in a wineglass of lukewarm water or in a wineglass of the 
above-mentioned solution of chalk). 

The treatment of chronic diarrhoeas by enemata is suitable in 
catarrhs of the colon and the rectum. In addition to those already 
described (page 181), I have seen excellent results from enemata of 
bismuth (a teaspoonful in 250 cubic centimetres of water). This is 
analogous to Fleiner's method for the treatment of gastric ulcer. 

2. Constipation 

In the treatment of constipation, bodily and mental rest may 
contribute toward a good result ; only in very severe cases is abso- 
lute rest in bed indicated. Experience shows that warm, frequently 
repeated fomentations have a favourable effect upon the pain. 

The chief indication to be met in catarrh of the intestine accom- 
panied by constipation is the removal of this symptom by appro- 
priate diet. In all essential features it is the same diet as that to 
be fully described in the chapter on Constipation, but with this 
important exception, that all foods which are rich in cellulose, 
or other indigestible substances, must be avoided. If, as is usually 
the case, we succeed in regulating the evacuations by the diet, the 
abnormal secretion of mucus gradually disappears without further 
treatment (see chapter on Membranous Enteritis). In these cases 
I do not believe purgatives should be given ; indeed, I have a 
suspicion that their use may cause, or at least aggravate, an intes- 
tinal catarrh. If directions as to diet do not suffice, I recommend 

* It is much to be regretted that the treatment of chronic intestinal catarrhs has 
not been undertaken at the above-mentioned springs. With appropriate installations 
for providing suitable diet (somewhat after the manner of Carlsbad), these springs 
would, in my opinion, take a prominent place in the treatment of intestinal catarrh. 



228 DISEASES OF THE INTESTINES 

mild enemata of rape-seed oil, oil of sesame, or olive oil ; of neutral 
soap (5 grams to 250 cubic centimetres of water), castor oil, cod- 
liver oil, soda, etc. (see page 179). Irrigation for the purpose of 
cleansing the intestine of mucus is a very useful adjuvant. The 
following solutions are to be recommended for this purpose : Lime 
water (3 to 4 tablespoonfuls to 1 litre of water), carbonate of soda 
(1 dessertspoonful to 1 litre of water), Carlsbad salt (in the same 
proportion). Other desirable agents for the same purpose have 
been mentioned on page 181. 

3. Constipation, alternating ivith Diarrhoea 

The same principles hold good as in the form just described. It 
is only necessary to decide which is the primary or predominating 
feature, and this can readily be ascertained by the use of a test diet 
for a few days. 

3. Membranous Enteritis 

Preliminary Considerations. — By membranous enteritis, or, 
still better, membranous colitis, we understand a form of catarrh of 
the large intestine which is characterized by three cardinal symp- 
toms : (1) A peculiar mucous formation ; (2) anomalies of intestinal 
function ; (3) painful spasm of the intestine. In addition, there are 
a few other collateral symptoms, which, however, have nothing to 
do with the clinical picture proper of the disease. 

The classification of membranous colitis with chronic enteritis 
does not altogether correspond to the views which prevail at the 
present time, especially among German authors. The predominant 
conception is that which Siredey 18 seems to have been the first to 
advance in 1869 — that the membranous mucous formation was the 
result of a peculiar secretory neurosis. Da Costa 19 , to whom we 
owe its first classical description, looked upon membranous colitis as 
of nervous origin. The German authors, in so far as they have 
expressed themselves concerning the pathology of the disease, do 
not agree, von Leube 20 and Rosenheim 21 are inclined to regard it as 
a neurosis of secretion. Ewald 22 takes a middle ground, and Noth- 
nagel 23 makes a sharp distinction between mucous colitis and mucous 
colic, one having an anatomical and the other a functional basis. 
The standard French authors (G. See 24 , Potain 25 , Alb. Mathieu 26 , 
de Langenhagen 2T ) rather incline to the view that there is a superfi- 
cial catarrh. On the other hand, American authors (Mendelson 28 , 
Einhorn 29 , and others) have recently laid stress on the nervous char- 



ACUTE AND CHRONIC INTESTINAL CATARRH 229 

acter of the affection. Yanni 30 also speaks of a myoangioneurosis 
of the intestine with hypersecretion of mucus. As far as I have 
seen, the latter idea has made a deep impression in medical circles, 
and has had an undeniable influence upon treatment. 

From personal observation I can say that it is difficult to come 
to a decision. There are cases in which the nervous, restless char- 
acter of the affection is very prominent, so much so that it is diffi- 
cult to believe that it has a material basis. On the other hand, 
there is no doubt in my mind that membranous colitis is frequently 
found in patients who are not at all neurotic, or in whom the neu- 
rotic stigmata are positively or probably the results of the disease. 
An unprejudiced estimate of the frequency of the two groups leads 
me to the opinion that the latter predominates. 

This much is certain : the idea that membranous enteritis is one 
of the phases of hysteria or neurasthenia must be rejected as too 
sweeping. 

Unfortunately, neither experimental pathology (Yanni ^ Aker- 
lund 31 ) nor pathological anatomy affords us much assistance as 
to etiology. We have but two clinical observations followed 
by autopsy — those of O. Rothmann 32 and of M. Rothmann 33 . In 
the former, although the entire intestinal tract was carefully 
examined by C. Ruge, nothing abnormal was found ; while in the 
second case, reported by the younger Rothmann,* all the character- 
istic lesions of a catarrh of the large intestine were demonstrated by 
a very thorough histological examination. Although it may seem 
venturesome to draw any conclusion from two findings so diamet- 
rically opposed to each other, yet there is no doubt that the posi- 
tive result has much greater significance than the negative one. 

Aside from the main question whether we are dealing with 
a functional or an inflammatory condition, there are a number of 
other etiological factors to be considered. First of all, the influ- 
ence of habitual constipation must be emphasized. According 
to the experience of most authors, habitual constipation is one 
of the most constant affections occurring together with mem- 
branous enteritis. A few (Ewald 34 , Einhorn 29 , and others) call 
attention to an antecedent diarrhoea as a cause. I have also seen 
such cases, but only after the use of astringent enemata. In addi- 
tion, numerous observers (Glenard M , A. Mathieu 26 , Ewald M , Boas 36 , 
Akerlund 31 , de Langenhagen 27 , Einhorn 29 , and others) have accen- 

* The report of 0. Rothmann does not state whether a histological examination 
was made. 

16 



230 DISEASES OF THE INTESTINES 

tuated the relationship between coloptosis and membranous enteri- 
tis. This etiological factor has a certain influence, but only in so 
far as it favours the establishment of habitual constipation. 

Attention has been called by French investigators to the rela- 
tion between membranous enteritis and uterine diseases (Ozenne % 
LetchefT ^ and others) ; but these observations seem rather to relate 
to accidental complications. It is well known, moreover, that uter- 
ine diseases, as well as abnormal conditions of the adnexse, may 
cause constipation by compression or adhesions, and thus predispose 
to membranous enteritis. 

Finally, at a recent date, various French investigators (A. Ma- 
thieu 39 , de Langenhagen 27 , Chevalier m ) have laid stress on a certain 
connection between membranous enteritis and intestinal lithiasis. 
The periodical formations of gravel, accompanied by severe colic, 
which had already been recognised and which was recently rede- 
scribed by Dieulaf oy 41 , are supposed by Mathieu 39 to be a constant 
feature of membranous enteritis. All that has been published on 
this subject simply goes to show a possible coexistence of intestinal 
lithiasis with the disease under consideration, but no proof has yet 
been offered that there is any etiological relation. 

Artificial membranous enteritis is a very important condition, 
which from a practical standpoint has received much less attention 
than it merits. I have frequently observed it after enemata of tan- 
nin, alum, glycerin, and nitrate of silver. In some cases the clinical 
picture of membranous enteritis already existed (see Case IT) ; but 
I have become convinced that the symptoms may be kept up and 
increased by irritant injections. Membranous enteritis is also ob- 
served as a sequel to acute enteritis. It is doubtful whether this con- 
dition is altogether identical with the one now under consideration. 

After these preliminary remarks, we will proceed to 

Symptomatology and Diagnosis 

When we analyze closely the description of the symptoms of 
membranous enteritis, as given by the most prominent authorities 
(Da Costa 19 , von Leyden 42 , Nothnagel 12 , Kitagawa 43 , Krysinski 44 , 
A. Mathieu 39 , Germain See 24 , de Langenhagen 27 , and others), we 
find such a lack of agreement that the question arises whether 
these authors are dealing with the same affection. In some of the 
cases it can be shown with certainty that the clinical picture be- 
longs essentially to the group of colica mucosa. Others are com- 
plicated by gastric atony, intestinal prolapse, appendicitis, etc. In 



ACUTE AND CHRONIC INTESTINAL CATARRH 231 

still others uterine complications exist. In one case, recently de- 
scribed by Henschen 45 , larvse of the fly were present in the intestinal 
canal. Others were undoubtedly due to artificial influences such 
as have been just mentioned. Finally, there are several cases (Mar- 
chand 46 , O. Rothmann 32 , Kichardiere 47 ) which, as far as concerns 
the bowels, gave no symptoms during life. 

E"or does this exhaust the list ; it would take too long to allude 
to all of them. TVe can only say that for diagnostic purposes mem- 
branous colitis is sometimes an independent disease, and sometimes 
is found in conjunction with other affections. It is thus easy to un- 
derstand that the clinical picture presents manifold exceptions and 
variations. 

I have thought it advisable, therefore, to select the following 
from the large number of cases which I have recorded, and in con- 
nection with them to discuss the diagnosis : 

Case I. A case of membranous enteritis, icith severe disturbances of nutrition, 
ichich had existed for many years. Permanent cure. 

Mrs. Regina B., twenty-seven years old, born in Poland, and for several years 
a resident of Berlin. 

The patient states that for seven years she has suffered from loss of appe- 
tite, eructations, pains in the stomach after the ingestion of food, flatulence, 
and persistent constipation. For some time past enemata have nearly always 
been required to obtain movements from the bowels, and the patient has often 
noticed membranous and tubular masses of mucus in the stools. These have 
sometimes appeared in such abundance that the stools consisted of almost 
nothing but them. The patient asserts that during this period she was very 
nervous and uneasy. She does not, however, remember having had any marked 
pain immediately before such mucous stools. At her first visit to the polyclinic 
(March, 1893) she looked very ill, was extremely emaciated, so that incipient 
phthisis was suspected, but not confirmed by examination. She was treated 
by irrigations of the intestine; the washings frequently showed masses of 
mucus, membranes of mucin, and tubular casts of various calibres. The sub- 
sequent treatment was wholly dietetic (" constipation diet "). 

Under the latter treatment and a course of waters the patient's condition 
improved materially ; she gained in weight to a considerable extent, and began 
to get a healthy colour. 

At my request she presented herself in March, 1895, and again in February, 
1899, for examination; she stated that her health had continued good, and 
that there was no longer constipation. Irrigation showed that the mucous 
masses were no longer present. 

Case II. Severe form of membranous enteritis, complicated by disorders of 
the stomach and bladder. Cure. 

Mrs. B., widow, Kloster Lehnin, near Brandenburg, thirty-six years old. 
The patient states that since the death of her husband and a sixteen-year-old 



232 DISEASES OF THE INTESTINES 

daughter she has been very nervous and irritable, sleeps badly, complains of 
tremor and spots before the eyes. 

The patient has suffered from extreme constipation since childhood ; has 
always used enemata and laxatives. In the last three years disorders of the 
stomach have appeared : poor appetite, nausea, but no vomiting, discomfort, 
and pressure in the epigastrium. Gradually she began to have attacks of se- 
vere pain in the epigastrium after eating, which came on even after a spoon- 
ful of milk. This pain radiated toward the sides and back, and was more 
severe after food not easily digested. The constipation increased so that 
four tablespoonfuls of castor oil and an enema of oil produced only a small 
evacuation. There was marked emaciation, and the patient was confined to 
bed for months. In the winter of 1895-96 she first noticed that after ene- 
mata pure mucus was passed, sometimes in the shape of little shreds, and 
sometimes larger aggregations in tubes or bands as long as half a metre. 
After passing these the patient used to feel better. With these complaints 
there was associated pain in the Madder from time to time, ending in the passage of 
a light-coloured urine of low density. On admission to the clinic in May, 1897, 
she complained of debility, weakness on walking, pains along the spine, ano- 
rexia, slight eructations, severe constipation, and the passage of mucus in the 
stools. 

Condition on admission, May 5, 1897 (with the omission of unimportant 
features) : Floating kidney on the right side ; fundus of the stomach at the level 
of the umbilicus. Loud splashing sounds in both iliac fossae, and to some 
extent also in the epigastrium. 

An evacuation followed irrigation of the intestine ; it resembled sheep dung, 
and was covered with small shreds of mucus ; it was small in quantity, and of 
a brown, or perhaps greenish brown colour. 

Palpation of the abdomen showed that the left iliac region was very tender; 
there was also slight tenderness in the epigastric region. 

A second irrigation on the same day showed abundant masses of mu- 
cus, several of the shreds measuring a few centimetres in length. They were 
white or yellowish brown in colour, some membranous, and some vitreous in 
appearance. 

Repeated irrigations gave the same result. The microscopical examination 
gave the usual findings. The stools were in other respects normal. Treat- 
ment : constipation diet and intestinal irrigations. 

In spite of these measures the constipation was not entirely relieved. Ene- 
mata could not be dispensed with. In the further history of the case the 
pains in the stomach and spine disappeared and the patient gained in weight. 
The abdominal pains were felt occasionally. The evacuations obtained by ene- 
mata frequently contained large shreds of mucus. The neighbourhood of the 
sigmoid flexure was still sensitive to pressure, but much less so than formerly. 
Treatment, aside from diet, consisted in pulv. glycyrrhizee comp., one tea- 
spoonful twice daily. 

June 21^ 1898. — The patient now has regular movements from the bowels ; 
the pains have almost entirely vanished ; weight and strength have increased. 
The evacuations are free from mucus. The region of the sigmoid flexure only 
slightly sensitive. 



ACUTE AND CHRONIC INTESTINAL CATARRH 233 

Case III. Membranous enteritis, with severe constipation and occasional 

acute colics. Previous history of ulcer of the stomach {or duodenum ?). 

Mrs. B.. resident of G.. forty-one years old. In her nineteenth year, four 
weeks after marriage, the patient suffered from acute peritonitis (gonorrhoea! 
infection ?). She was confined to bed for seven weeks, and had pains in the 
abdomen for some time afterward. 

As a girl she suffered from constipation, which became worse after the 
attack of pelvic peritonitis. Two years later she had an attack of pleurisy on 
the right side, following which she began to have a persistent gastric pain. In 
the year 1885. after the appearance of tarry blood in the stools, a gastric ulcer 
was diagnosed. In 188? there was another attack of melsena. and in 1890 
vomiting of blood. She underwent von Leube's treatment for ulcer, at 
Wurzburg. Improvement resulted, but only under the strictest diet. Mucus 
was first noticed in the stools in 1888. the bowels being extremely constipated. 
The same fact was noted during the treatment for ulcer in 1890. Gradually 
severe pains developed on both sides of the abdomen at the level of the umbili- 
cus; these were only relieved by a free movement of the bowels. Sometimes 
nothing but mucus was passed, and at other times it was accompanied by faeces. 
When mucus only was passed there was no alleviation of the symptoms. Such 
mucous evacuations occurred every four to six weeks. In the intervals niueu- 
was either absent or only found in small quantity. 

Present condition : Sensitiveness on pressure localized at 1-| centimetres to 
the right of the median line at the junction of the middle and lower thirds of 
the space between the xiphoid cartilage and the umbilicus. Intestinal area 
quite free from sensitiveness. Irrigation of the intestine on two occasions gave 
only a very small quantity of mucus. 

Case TV. Development qf membranous colitis during pregnancy^ with severe 
pyrexia. Normal labour. Cessation of the fever. Continuance of the colitis. Cur? 
by producing regular movements of the bowels. 

Mrs. H.. twenty-five years old. The patient, who was healthy, with the 
exception of a varying degree of constipation, suddenly took sick in the sixth 
month of pregnancy, on June 19. 1898. with a chill and a fever reaching 39. 6 C C. 
[103.3° P.], She complained of pain in the lower part of the abdomen on the 
right side, which pain radiated to the lumbar region and down the right leg. 
Examination yielded no positive results. The illness during the following four- 
teen days presented the picture of a septic infection. 

In the beginning of July the fever and chills abated, followed on the 10th 
by symptoms similar to those at the onset. About the middle of the month 
the stools for the first time showed mucous casts, which were both tubular and 
ribbonlike, and 10-12 centimetres in length. 

For the following particulars I am indebted to her family physician. Dr. 
Laux. of Oldenburg : 

On the 18th of July, having just returned after an absence from town. I -aw 
these evacuations for the first time. Though quite fresh, they had a penetrat- 
ing odour, as if in a state of decomposition, which was also suggested by their 
dirty, grayish green colour. By means of two or three large enemata. I succeeded 
in removing more or less abundant masses of faeces, with a resulting: subsidence 



234 DISEASES OF THE INTESTINES 

of the strong odour, and a return to the usual colour. Under this treatment the 
chills and fever disappeared, and the subjective symptoms improved to some 
degree. On August 1st delivery occurred, setting in with a chill and fever, but 
otherwise normal in its progress. The puerperal period was uneventful. Since 
then there have been, off and on, evacuations of mucous shreds, but finely broken 
up and in small quantity. On the day before such passages there is pain, which 
is relieved by the evacuation. Persistent constipation exists, but is controlled 
by enemata. Regulation of the bowels by constipation diet in my clinic 
resulted in a complete arrest of the mucous discharge. 

The reported cases of membranous enteritis show an extraor- 
dinary preponderance of the female over the male sex. All the 
authors agree on this point. Litten found 80 per cent and Kita- 
gawa 90 per cent in women ; Einhorn found, in a total of 20 cases, 
2 men and 18 women, or about the same relation as the last-named 
author. This is not surprising when we consider the prevalence of 
coloptosis and constipation among women. 

The greatest number of cases of membranous enteritis occur 
during the second, third, and fourth decades of life ; it is only rarely 
found during the later years of life, and rarest of all in childhood. 
A few cases have been reported in the newborn (Longuet **, TJ11- 
mann 49 ) and in the early years of childhood (Lowenstein 50 ). 1 have 
seen a well-marked case in a two-year-old girl of very nervous 
temperament. 

The chief complaints of the patients relate to disturbances of 
the intestinal functions. Constipation is, as I have repeatedly 
said, the condition in the majority of cases ; diarrhoea is certainly 
atypical. Paroxysmal pains are a very frequent symptom. They 
usually mark the onset of attacks, and are of an exceedingly acute 
colicky type, so that they often cause symptoms of collapse. The 
attack ends with the passage of fasces and membranous mucus, or 
of the latter alone. The stools have the usual appearance of spastic 
dejections. These intestinal colics are, however, by no means a 
necessary symptom; they may be slight, or entirely absent, or 
there may be colicky pains without passage of mucus ; or, finally, 
membranes may be passed with or without attacks of pain. If we 
are successful in regulating the bowels, the painful intestinal spasm 
and the mucous evacuations usually cease, or appear only occasionally 
and to a limited extent. 

Together with these symptoms there may be various other com- 
plaints, partly of a nervous and partly of an organic origin ; these 
have nothing to do with the disease as such ; they are nothing but 
accessory symptoms or complications. 



ACUTE AND CHRONIC INTESTINAL CATARRH 235 

In typical cases the objective signs are sensitiveness over the 
colon or portions of it, and the passage of mucus. 

In the majority of cases the sensitiveness is noted over the 
descending colon or the sigmoid flexure ; in other cases over the 
caecum and ascending colon, and apparently very much less fre- 
quently over the transverse colon. This sign alone is not character- 
istic of membranous colitis, since, as we have noted above, it is met 
with in ordinary catarrh of the large intestine ; but in the former 
affection it is much more pronounced than in simple catarrh. The 
tenderness which under certain circumstances is not much less than 
in appendicitis, seems to bear a positive relation to the process, for 
it disappears or diminishes as cure or improvement occurs, to return 
in a surprising way when a relapse occurs. 

The expulsion of mucus or membranes is the most decisive 
clinical sign. It is hardly conceivable that these formations should 
be mistaken for tapeworm, food residues, etc., or anything else, or 
that the affection should be confounded with croupous enteritis, if 
careful macroscopic and microscopic examination is made. Three 
kinds of mucous formation can be distinguished: 1, unformed, struc- 
tureless mucus ; 2, hyaline, tubular formations, which under cer- 
tain conditions form a cast of the internal surface of the intestine ; 
3, membranous mucus, sometimes firm and sometimes spongy in 
consistence. The chief constituent of these secretions — for there is 
no doubt on this point at the present day — is mucus and an albu- 
minoid body, the latter depending upon the varying admixture of 
cellular elements. According to careful investigations of Kita- 
gawa 43 , M. Eothmann 33 , Akerlund 31 , Ad. Schmidt 51 , and Pariser 52 , 
there is no fibrin present, and they are thus differentiated from the 
exudates in intestinal diphtheria. 

In doubtful cases a microscopic examination is a useful supple- 
ment to the results of the macroscopic investigation. Even without 
the addition of acetic acid, but better with it, there will be found 
the peculiar threadlike substance in which cells, nuclei, and detritus 
are embedded in variable quantity. Most of the cells have lost their 
characteristic appearance (see Fig. 16, page 118), fresh, unchanged 
cells being rarely found. Opinions differ as to the cause of this 
degeneration. Nothnagel 12 thinks it is due to desiccation. Kita- 
gawa regards it as a degeneration process (coagulation necrosis). 
As Ad. Schmidt 51 has recently shown, it is due to an infiltration of 
fatty soaps, on the removal of which the cells regain their bright, 
transparent appearance. There are also found a greater or less 



236 DISEASES OF THE INTESTINES 

number of leucocytes, occasionally Charcot- Ley den crystals, and 
micro-organisms of various kinds. None of these have any special 
significance. 

Complications are very frequent. Associated disease of the 
uterus and adnexse and intestinal lithiasis have already been men- 
tioned. The literature of the subject shows that albuminuria, 
pyrexia, epileptic attacks, tachycardia, dyspnoea, neuralgia, tremor, 
somnolence, amblyopia, and melancholia are occasional accompani- 
ments. Einhorn 29 found that out of twelve cases achylia gastrica 
was present in five, and in several cases the gastric motor function 
was increased. 

The course of membranous colitis, like that of habitual constipa- 
tion, is exceedingly chronic, but like it, shows marked remissions 
and intermissions. The general nervous symptoms follow very 
closely the increase or diminution in the colicky attacks. 

The diagnosis of membranous colitis can be made in most cases 
from the symptoms which have been detailed, especially from the 
results of repeated intestinal irrigation. This should not be post- 
poned in any case. It will show — and I particularly insist upon this 
— that the membranous formation does not appear occasionally or 
suddenly, but that smaller or larger masses of mucous or tubular 
formations may often be identified during the intervals between the 
attacks. Some difficulty exists in the differentiation between simple 
colitis and the membranous variety, for we meet with cases which 
might with equal propriety be put in either class. In general, those 
cases in which actual membranes are passed should be put in the 
present class, and the remainder classed with the other forms of 
enteritis. The other fact already mentioned, that membranous 
enteritis may arise from artificial causes, must again be emphasized 
and should always be borne in mind. 

Treatment 

Until recently very unfavourable or doubtful results were ob- 
tained from the treatment of membranous colitis, and at the pres- 
ent time the disease is frequently obstinate, and yields reluctantly 
to therapeutic influences. This is especially true of those cases in 
which a hysterical element is prominent. 

In cases of a conspicuously catarrhal type much more may be 
expected from treatment. 

In accordance with our conception of the nature of the disease, 
chief stress is to be laid upon the treatment of the enteritis, with- 



ACUTE AND CHRONIC INTESTINAL CATARRH 237 

out underestimating the importance of such elements as neuras- 
thenia, enteroptosis, anaemia, or faulty nutrition. 

We have already said, and it has been recently emphasized by 
von Noorden 53 , that the chief feature of the treatment of mem- 
branous enteritis consists in the relief of the constipation by an 
appropriate diet, von Noorden 53 rather recklessly states that one 
rich in coarse constituents, with abundance of butter and fats, is 
appropriate. I have not had any experience with this method, but 
I can not suppress the thought that such a coarse diet may gradu- 
ally set up intestinal irritation. I still believe in the view, expressed 
some time ago 54 , and repeated recently, that a constipation diet, with- 
out husks or cereals, is the only suitable and successful dietary in 
membranous enteritis. Einhorn 29 has very recently taken a similar 
position. 

It is not necessary to enter here upon the details of this diet, as 
it differs very little from that to be described in the chapter on Con- 
stipation. We agree with von Noorden as to the cardinal impor- 
tance of an abundant supply of nutriment, since the patients are 
generally individuals who are depreciated by anaemia, faulty nutri- 
tion, or frequent pregnancies. I have seen excellent results from 
the employment of forced nutrition, always, of course, with due 
attention to the question of constipation. 

In those cases in which the constipation is overcome by diet, 
local treatment of the intestinal tract is superfluous ; in other cases 
it may be of advantage. According to Fleiner, enemata of oil are 
very successful, but I have not had sufficient experience with them 
to be able to say whether their effect is lasting. Careful irrigation 
with unirritating substances, such as physiological salt solution, so- 
dium carbonate, or Carlsbad salt, may be of material assistance. On 
the other hand, caution must be recommended in the use of astrin- 
gent solutions which are apt rather to increase the difficulty (tannin, 
alum, nitrate of silver, etc.). For the same reason I consider the 
stronger purgatives contra-indicated, while the milder laxatives, such 
as rhubarb, tamarinds, liquorice powder, and preparations of sagrada, 
may be of use if dietetic measures are not sufficient. Other drugs 
(ext. fl. hydrast. canadensis, bromids, opiates) have been recommended, 
but a real influence upon the morbid process is hardly to be ex- 
pected from them. Perhaps the painful colics may be ameliorated 
by suppositories containing codeia, belladonna, or opium. In gen- 
eral, the continuous or intermittent application of moist, warm, or 
hot poultices, in connection with aromatic infusions, will suffice. 



238 DISEASES OF THE INTESTINES 

In cases of membranous colitis with prominent nervous disturb- 
ances hydrotherapeutic procedures are very valuable (half baths, 
shower baths, douches, wet packs, etc.). Change of air and a warm 
climate sometimes contribute to a cure. The mineral waters do not 
promise great or permanent results. 

Among the curiosities of treatment, I may mention that the sur- 
geons have attempted to cure membranous colitis by the establish- 
ment of an artificial anus (Hale White and Golding Bird 55 , F. 
Franke 56 ). They claim to have had successful cases. 



LITERATURE 

1. G-affky. Deutsch. med. Wochenschr., 1892, No. 74. 

2. Kjellberg. Nordiskt med. Arkiv, 1869, Bd. i. 

3. Hermann. Wiener med. Wochenschr., 1890, S. 1044. 

4. Miihlhauser. Berliner klin. Wochenschr., 1873, S. 595. 

5. Kobler. Wiener klin, Wochenschr., 1890, No. 28-31. 

6. Fischl. Prager Vierteljahrsschrift, 1878, Bd. cxxxix, S. 27. 

7. Stiller. Wiener med. Wochenschr., 1890, No. 78 u. 79. 

8. Turner. Practitioner, October, 1894. 

9. Strtimpell. Lehrbuch d. spec. Pathologie u. Therapie, Bd. i, 1883, S. 565. 

10. Fleischer. Krankheiten d. Speiserohre d. Magens u. Darmes, S. 1226. 

11. Nothnagel. Darmkrankheiten, S. 98. 

12. Nothnagel. Beitrage zur Physiologie u. Pathologie d. Darms. Berlin, 

1884, S. 191. 

13. Biedert und Langermann. Diatetik u. Kochbuch. Stuttgart, 1895. 

14. Einhorn. Archiv f. Verdauungskrankheiten, Bd. i, S. 158, 1895. 

15. Oppler. Deutsch. med. Wochenschr., 1896, No. 32. 

16. Pawloff. Die Arbeit d. Verdauungsdriisen. Wiesbaden, 1898. 

17. Jaworski. Therapeutische Monatshefte, 1898, Heft 2. 

18. Siredey. Union medicale, 1869. 

19. Da Costa. Amer. Jour, of the Medical Sciences, p. 321, 1871. 

20. von Leube. Specielle Diagnose innerer Krankheiten, 1889, S. 270. 

21. Rosenheim. Pathologie u. Therapie d. Krankheiten d. Darms, 1893, S. 132. 

22. Ewald. Nineteenth Century Practice of Medicine, 1897, p. 265. 

23. Nothnagel. Darmkrankheiten, S. 139. 

24. G. See. Bullet, medic, 1893, p. 1167. 

25. Potain. Semaine medicale, 1887, p. 341. 

26. Alb. Mathieu. G-az. des hopitaux, 1894, 27 Oct. Cfr. also Therapeutique 

des maladies de l'intestin. Paris, 1895. 

27. de Langenhagen. Semaine medicale, 1898, No. 1. 

28. Mendelson. New York Med. Record, Jan. 30, 1897. 

29. Einhorn. Archiv f. Yerdauungskrankheiten, Bd. iv, Heft 4, 1898, and 

New York Med. Rec. 

30. Yanni. Rivista clinica, 1888, No. 4. 

31. Akerlund. Archiv f. Verdauungskrankheiten, Bd. i, S. 396, 1895. 



ACUTE AND CHRONIC INTESTINAL CATARRH 239 

32. O. Rothmann. Deutsch. med. Wochenschr., 1887, No. 27. 

33. M. Rothmann. Zeitschr. f. klin. Meclicin, 1893, Bd.xxii. 

34. Evvald. Deutsch. med. Wochenschr., 1893, No. 41. 

35. Glenard. De TEnteroptose, 1889. 

36. Boas. Deutsch. med. Wochenschr., 1893, No. 41. 

37. Ozenne. Journal de Medecine, 31 Dec, 1893. 

38. Letcherf. De la colite muco-membraneuse chez les uterines. These de 

Paris, 1895. 

39. Alb. Mathieu. Soc. medic, des hopit., 22 Mai, 1896. 

40. Chevalier. Contribution a l'etude de la lithiase intestinale. Paris, 1898 

(with literature). 

41. Dieulafoy. Presse medic, 1895, 10 Mars ; and Acad, medic, 1897, 23 

Mars. 

42. von Leyden. Deutsch. med. Wochenschr., 1882, No. 16 u. 17. 

43. Kitagawa. Zeitschr. f. klin. Medicin, Bd. xviii, 1890. 

44. Krysinski. Enteritis membranacea. Inaug. -Dissert., Jena, 1884. 

45. Henschen. Wiener klin. Rundschau, 1896, No. 33. 

46. Marchand. Berliner klin. Wochenschr., 1877. 

47. Richardiere. Union medicale, 1895, No. 1. 

48. Longuet. Rec de mem. de med. milit , 1878. 

49. Ullmann. Deutsch. med. Wochenschr., 1894, No. 2. 

50. Lowenstein. Ibid., 1889, No. 2. 

51. Ad. Schmidt. Zeitschr. f. klin. Medicin, Bd. xxxii, Heft 3 u. 4, 1897. 

52. Pariser. Deutsch. med. Wochenschr., 1893, No. 41. 

53. von Noorden. Zeitschr. f. prakt. Aerzte, No. 1, 1898. 

54. Boas, von Leyden's Handbuch d. Ernahrungstherapie, 1898, Bd. ii, lte 

Abth., S. 309. 

55. Hale White and Golding Bird. Clinical Society, 1896. 

56. F. Franke. Mittheilungen aus d. Grenzgebieten, etc, Bd. i, 1896, S. 379. 



CHAPTER XIV 
DYSENTERY 

Definition. — An infectious disease with lesions localized in 
the large intestine and characterized clinically by the occurrence 
of frequent bloody, mucous or serous dejections associated with 
tormina and tenesmus with more or less marked constitutional 
manifestations. 

Varieties. — According to the etiology a bacillary and an ame- 
bic form of the disease are distinguished. Unfortunately this 
classification is not an absolute one, since the two varieties may be 
associated in the same case (Kartulis). 1 

Distribution. — The distribution of bacillary and amebic dys- 
entery is now so widespread that to speak of the endemic home of 
either variety has only a historical significance. A. Hirsch 2 says 
" that dysentery had the widest distribution over the surface of 
the earth at all historic times, as it has at the present era, and 
that it spares no large domain of the inhabited portion of the 
earth." 

By nature a tropical or semi-tropical disease, the increased 
facilities of transportation of the present century, together with 
the occupation and invasion of tropical countries by the colonial 
troops of non-tropical nations (Great Britain in India and Africa, 
the United States in the Philippines and Puerto Rico, Germans 
in Africa, etc.), have tended to disseminate the germs of 
this pestilence over the face of the earth. Even in the short 
time since Loesch 3 (1875) first found the ameba dysenteria? in 
a genuine case of dysentery, similar cases have been reported by 
Epstein 4 and Hlava, 5 in Prague; Osier, 6 Councilman and La- 
fleur, 7 Simon, 8 Xasse, 9 Musser, 10 Eichberg, 11 Dock, 12 Stengel, 13 
and Lutz 14 in America; Calandruccio, 15 Vivaldi, 16 and Fenoglio 17 
(Italy and Sardinia); Massiutin 18 (Kiew), Kartulis 1 (Athens), 
Cahen 19 (Graz), L. PfeifTer 20 (Weimar), Kruse and Pasquale 21 
(Egypt), Lobas 22 (Sachalin), Kovacs 23 (Austria), Baelz 24 (Ja- 
pan), and many others. 
240 



DYSENTERY 241 

These reports from such widely separated sources show the 
futility of attempting an etiological distinction between " endem- 
ic " and " epidemic " dysentery. Sporadic cases of either bacil- 
lary or amebic forms of the disease may occur anywhere and in 
almost any clime, so that careful clinical examinations are always 
required to determine the nature of the individual case. 

Historical. — The earliest reference to dysentery is in the papy- 
rus Ebers. In the medical literature of India it is referred to 
as " atisar." The historian Herodotus chronicles an epidemic 
in Thessaly. It was first recognized as a distinct disease by Herod- 
otus 430 b. c. Galen, 164 a. d., gives a fairly accurate clinical 
picture of the disease. Sennertus (1584) says: "Dysentery con- 
sists in frequent bloody dejections from the bowels, with pain in 
the abdomen and ulceration of the intestines." 

The wide-spread havoc caused by this disease even in modern 
times is evidenced by such epidemics as occurred during the fam- 
ine in Naples, 1764; in the central regions of Europe, 1845; in 
France, 1857 (7,119 deaths) ; in Sweden the middle of the last 
century (20,000 deaths) ; in Algeria, 1867; in Japan, 1890 (801 
cases with 221 deaths) ; 1891 (8,390 cases with 2,153 deaths) ; 
1897 (89,400 cases with 22,300 deaths), during the Anglo-Boer 
War in Africa and the Spanish-American War in the Philip- 
pines, etc. 

Nature and Causes of Epidemics. — The amebic variety hardly 
calls for consideration under this heading. Such epidemics as 
have occurred outside of tropical countries were limited and 
showed little tendency to spread; the reason being evidently that 
the viability and proliferative powers of the amebse is far below 
that of the bacteria of dysentery. The bacteria of dysentery, on 
the other hand, are able to withstand seasonal, climatic, atmos- 
pheric and telluric conditions, and retain their virulence for an in- 
definite time. Cheyne 25 saw dysentery begin in Ireland in sum- 
mer and last through the autumn and winter, only terminating in 
the spring. In Siberia (1732) dysentery continued till January, 
in spite of a severe winter. Czernicki 25 relates that two French 
squadrons with perfect sanitary conditions encamped during the 
end of August, 1875, on the field of Chalons; dysentery broke out 
on the 1st of September, and only after the outbreak of the epi- 
demic it was discovered that a regiment of cavalry in which were 
numerous cases of dysentery had previously encamped on the same 



242 DISEASES OF THE INTESTINES 

ground. Fifteen years later an epidemic of dysentery broke out 
among a part of the troops quartered on the field of Chalons 
where regiments attacked by the disease had encamped the year 
before. The epidemic in Sweden (1852) which killed thousands, 
had a local character at first. It began in a few isolated dis- 
tricts and in successive years advanced over the country. These 
facts prove not only that a focus of dysentery once established 
tends to remain permanently, but also that there is a marked 
tendency for the disease to spread. 

The bacteria of dysentery occur in the soil in circumscribed 
foci. Some departments in Brittany and France are noted for 
this. These nidi under favorable conditions (the crowding to- 
gether of individuals in camps, hospitals, and institutions, famine, 
and deficient sanitation) form the starting-point of epidemics. In 
the city of Rio de Janeiro, sporadic cases occur throughout the 
year; every summer an epidemic that is limited to the lunatic 
asylum breaks out, but disappears at the end of summer 
without having spread over the city. 

Etiology. — Although essentially a disease of famine and war, 
these circumstances in themselves are not sufficient to produce an 
epidemic. Nor has any relation at all been established to such 
factors as climate, atmospheric conditions, temperature, malaria, 
etc. Some instances go to show that on an infected soil exposure 
to wet and cold may precipitate an epidemic. Thus, during the 
Seven Years' War dysentery broke out among the English army 
on the eve of the battle of Dettingen: the crossing of a river in 
Africa by a French expedition column caused an epidemic. The 
marshes and swamps which breed malaria are not necessarily hot- 
beds of dysentery. The island of Reunion is exempt from malaria 
but infected with dysentery. The same is true of Grande Terre 
on the island of Guadaloupe ; whereas exactly the reverse condition 
obtains in Basse Terre on the same island. Madras in India is a 
hot-bed of dysentery and least victimized by malaria. 

The chief source of infection is the drinking of contaminated 
water. With imperfect sewerage, such as is found in country dis- 
tricts, in the crowded camps of armies, etc., the drainage from 
the privies always infects the drinking-water. Pringle, speak- 
ing of infection among armies, says : " In camps the contagion 
passes from the patient to his comrades in the same tent, and 
thence perhaps to the neighbouring tents ; the rotten straw becomes 



DYSENTERY 243 

infectious ; but the principal source of infection lies in the privies 
after they have received dysenteric excrements." 

Woodward, 26 Gemmel, 27 Kartulis * and many of the observers 
who studied amebic dysentery occurring among the British troops 
in the tropics, traced the infection to contaminated drinking- 
water. 

Bacteriology. — Although numerous attempts have been made 
by various observers throughout the world to determine the bac- 
teria of dysentery, the results up to the time of Shiga's publication 
in 1897 28 have been so inconclusive and at variance with each 
other, that little dependence could be placed on them. Klebs, 29 
Prior, 30 and Ziegler 31 were among the first to describe bacteria 
associated with dysentery, but their results now have only a his- 
torical value. Hlava 5 cultivated nineteen different varieties of 
bacteria from cases of " epidemic " dysentery, but his animal ex- 
periments failed. Chantemesse and Widal, 32 in five cases, claim to 
have obtained a bacillus which, injected into guinea-pigs, caused 
diphtheritis. Their results, however, were not confirmed by Grigo- 
riew. Some observers, among them Arnaud, 33 Celli and Fiocca 34 
and Escherich, 35 have isolated a bacillus which they believe is a 
colon bacillus of intensified virulence. Arnaud found this bacil- 
lus in fifty-three cases at Tunis. Rectal injections of bouillon 
cultures (the temperature of which had been raised to 60-80° C.) 
produced a fatal and characteristic dysentery in two dogs. Celli 
and Fiocca examined sixty-two cases of sporadic, epidemic and 
tropical dysentery in Italy and Egypt. Their work is of value, 
special reference having been given to the ameba coli as a possi- 
ble factor. Cultures of their bacillus as well as the toxins pro- 
duced gave positive results with animals. Escherich ascribes 
the contagious colitis of children (which is clinically similar to 
catarrhal dysentery) to the colon bacillus. During an epidemic 
in Japan Ogata 36 isolated a fine bacillus, which liquefied gelatin 
and was Gram-positive. Cultures of this bacillus introduced by 
mouth, rectum or hypodermatically, produced intestinal ulceration 
in cats and guinea-pigs. Vivaldi 16 found the same organism at 
Padua in twenty-three cases. Since then it has not been found 
again. Zancarol 37 (Alexandria), Sylvestri 38 (Turin), Bertrand 
and Bauscher 39 (France), and Ascher 40 (Germany), attribute 
dysentery to pyogenic cocci. 

During an epidemic in Cochin China Calmette 41 isolated the 



24:4 DISEASES OF THE INTESTINES 

bacillus pyocyaneus. This same organism was also found by 
Lartigau 4 " in a small epidemic in Xew York State, and by Adami 
in Canada. 

Bacillus Shiga. — While investigating the Japan epidemic of 
1897, Shiga 2S endeavoured to isolate an organism which would con- 
form to the following requirements: (1) It must occur constant- 
ly; ( 2 ) should not be normally present in the intestines ; ( 3 ) it 
must be pathogenic for animals; (4) it must show the Gruber- 
Widal agglutination reaction with the serum of patients. These 
conditions were fulfilled by a bacillus which he was able to culti- 
vate in all cases of dysentery. The Shiga bacillus is a short rod 
without spore formation, rounded at the ends and having slow 
movements; morphologically it belongs to the typhoid group. It 
grows on ordinary media, does not liquefy gelatin, does not coag- 
ulate milk or ferment glucose, shows no indol production. It is 
Gram-negative. It is agglutinated by even well-diluted sera of 
dysenteric patients. 

Bacillus Flexner. — A bacillus very similar to that of Shiga 
was isolated by Flexner 43 from cases of dysentery in Manila. 
This bacillus, too, was not found either in healthy human beings 
or those sick from any other disease. Marked Gruber-Widal reac- 
tions were obtained with the serum of the host or others suffering 
from dysentery. At the time Flexner believed that the bacillus 
was identical with the Shiga bacillus. Several small cultural 
differences have, however, been discovered, viz., the production 
of indol, the development of acid from mannit. Martini and 
Lentz would appear to be correct, therefore, in maintaining that 
the Shiga type and the Flexner Manila type are not identical. 
There is, however, no ground for the assertion that the Flexner 
bacillus was not the cause of dysentery in the Philippines. 
Strong and Musgrave continued Flexner's work. They found 
the bacillus in many acute and some subacute cases. In 
111 fatal cases occurring among soldiers, twenty-one were classed 
as acute specific (bacillary) dysentery, eleven as subacute spe- 
cific dysentery, seventy-nine as amebic. In 1899 Kruse 44 found 
the Shiga bacillus during epidemics in Germany, and Spronck 45 
in Holland. 

E. B. Yedder and C. W. Duval 46 (1901), working under the 
direction of Flexner, found his bacillus in five cases in Philadel- 
phia and in three cases in the Lancaster County Almshouse. 



DYSENTERY 245 

Duval and Basset (1902) in Baltimore again found this ba- 
cillus in cases of dysentery at the Children's Hospital; (also in 
some cases of summer diarrhoea?) Their theory, however, that 
summer diarrhoea and dysentery are related diseases is without 
sufficient foundation. 

With the exception of the epidemics at Tuckahoe, "N. Y., and 
Xew Haven, Conn, (which were of the Shiga bacillus variety), all 
investigated epidemics of dysentery in this country have been 
shown to be due to the Flexner Manila bacillus. In Europe the 
Shiga bacillus has been found in all the more recent epidemics 
with one exception, in which a different bacillus was found. 

Amebce. — Although amebse had been found byLambl 47 (1860) 
in a case of enteritis and by Lewis 48 and Cunningham 49 in cases 
of cholera, no relationship was established between a specific 
pathogenic ameba and any disease. Loesch 3 (1875) was the first 
to find the ameba in a case of dysentery and to consider it an 
etiological factor in the disease. This ameba {ameba coli Loesch) 
is a unicellular circular or ovoid protoplasmic body 15-35 TTt in 
size. The protoplasm is coarsely granular, partly hyaline. The 
limiting membrane or ectosarc is visible as a hyaline process only 
during the extrusion of pseudopodia?. In the endosarc are seen 
fine granules and food detritus (bacteria, starch granules, epithe- 
lial cells and blood cells, etc.). The amebse have a round, pale 
nucleus and a nucleolus ; the nucleus moves while the ameba is act- 
ive. In the cell body, one, two or more vacuoles are also seen 
which show a continual variation in outline. There are no con- 
tractile vacuoles. The amebse move very slowly, and in a char- 
acteristic fashion by the protrusion of pseudopodiae. A clear 
hemispherical knob composed of the ectosarc projects from some 
point on the surface and gradually enlarges, the flow of proto- 
plasm towards this point being indicated by the motion of the 
granules. 

Robert Koch (1883) was able to confirm the findings of 
Loesch in five cases of dysentery in Egypt. However, no great 
importance was attached to these investigations until Kartulis 1 
(1885) found the amebse repeatedly in cases of endemic dysen- 
tery and was unable to find them in other diseases (typhoid, tuber- 
culosis, etc.), and thereupon declared them to be the cause of en- 
demic dysentery. Up to the year 1889 he had collected 500 cases. 
Councilman and Lafleur, 7 Kruse and Pasquale, 21 and many other 
17 



246 DISEASES OF THE INTESTINES 

observers, from clinical observations and animal experiments en- 
deavoured to uphold bis claim that the so-called endemic dysentery 
was of amebic origin. On the other hand Grassi, 50 Calandruccio, 15 
Massiutin, is Gasser, 51 Sclmberg, 52 and others, having found the 
aniebae not only in other intestinal diseases, but also in persons 
enjoying perfect health, denied the correctness of KartuHs's con- 
tention. 

Thus, Grassi (1882-1888) found amebse in typhoid, cholera, 
pellagra, and colitis secondary to tumors. Sclmberg found that in 
health the presence of amebse depends on the alkaline reaction of 
the lower colon and the consistency of the faeces. After the ad- 
ministration of laxatives (especially of Carlsbad salts) aniebae are 
found in the upper colon together with other parasites, viz., flagel- 
lates, trichomonas and incomonas. 

The great difficulty in reconciling the contradictory state- 
ments of Kartulis and his school with those of his opponents has 
always been and is still the impossibility of securing a pure, bac- 
teria-free culture of amebse. Fractional sterilization combined 
with washing with sterilized water and partial filtration, as well 
as other methods, all fail to bring about the desired result. Kar- 
tulis, Kruse and Pasquale, by injecting the pus of liver abscesses 
from which no bacteria could be cultivated on the ordinary media, 
into cats, and obtaining a characteristic amebic dysentery, believed 
that they had definitely settled the controversy. These experi- 
ments are now known, however, to be faulty, since negative results 
with more varied culture media are necessary to conclude that 
any specimen of pus is sterile. 

Shardinger 53 was able to produce a bacteria-free culture of 
amebse, but in such culture the amebse were smaller, possessed 
little motility, and could not be inoculated upon fresh culture 
media. 

It is certain that up to the present time no satisfactory produc- 
tion of dysentery in cats with cultures of aniebae relatively free 
from bacteria has been accomplished. TTe are nevertheless war- 
ranted in assuming that there are two varieties of amebse found in 
man, one pathogenic, the other a pure saprophyte. 

Quincke and Roos 54 classify the amebse found in man as (a) 
phagocytic for red blood cells and pathogenic for man and cats; 
(b) non-phagocytic and non-pathogenic. The pathogenic variety 
(amebce dysenteries) is identical with the amebce coll Loesch and 



DYSENTERY 247 

the amebce fells. To the non-pathogenic variety the name amebce 
coli mitis is applied. 

I. Acute Bacillary Dysentery. — The extent and variation in 
the pathological lesions found in the intestines depend upon the 
nature of the epidemic. Although the changes in the intestines 
are in the main similar, the duration and severity of the toxic and 
inflammatory processes give rise to differences. To what extent 
the various epidemics differ, a comparison of the mortality of the 
epidemic at Tuckakoe, X. Y. (about 5 per cent.), with that of the 
epidemic in Japan, 1890 (about 26 per cent.), can readily demon- 
strate. The inflammatory process may be restricted to any one 
portion of the large intestine, and occasionally extends beyond the 
ileocecal valve to the lower portions of the small intestine. The 
lesions found are those of a catarrhal, croupous (diphtheritic) or 
hemorrhagic inflammation. 

a. Catarrhal form. — This is either only a preparatory stage 
to the croupous and hemorrhagic varieties, or else a mild type of 
the disease, without any mortality except in very young children. 
The changes are the same as those of a severe acute intestinal 
catarrh, viz., the mucous membrane of the bowel is swollen, in- 
jected, and hypersemic, frequently showing ecchymoses varying in 
number, especially in the highest portions of the folds. The in- 
jection of the mucosa gives it a peculiar striated appearance. The 
surface is coated with a yellowish fluid streaked with blood. 

b. Croupous and hemorrhagic form. — The transition from the 
catarrhal to the croupous stage is not sharply marked, one form 
merging imperceptibly into the other. The lower part of the small 
intestine and the entire large intestine are hyperaBmic and swollen, 
the lumen in places being almost obliterated. The exudate as- 
sumes a more purulent, frequently bloody character, and here and 
there are seen small white elevations, which can be removed with 
difficulty, giving rise to defects in the mucosa. Characteristic of 
croupous dysentery is the destruction of the mucosa progressing 
from the surface to the deeper layers, associated with necrosis and 
a croupous (diphtheritic) infiltration of the epithelium. This co- 
agulation necrosis may be so extensive that in the severer cases the 
mucous membrane appears to be covered with a bran-like layer 
composed of necrotic epithelium and mucus generally mixed with 
blood and pus cells. Perforation is unusual, the muscular coat 
affording a strong barrier to the encroachments of the Mamma- 



248 DISEASES OP THE INTESTINES 

tory process. Defects in the mucosa usually result. They are, 
however, never large and do not present the undermined appear- 
ance and fistulous connecting tracts described by Councilman and 
Lafleur, in amebic dysentery. The ulcers vary from the size of a 
pin's point to a pea, and are most numerous in the sigmoid flexure 
and at the flexures of the colon. They may be so numerous as to 
give a sieve-like appearance to the gut. 

Histologically, changes are found in the mucosa, submucosa 
and muscularis, most marked, however, in the former. The mu- 
cous membrane is hypersemic and of a deep bluish-red colour. In 
the mucosa we find a coagulation necrosis with exudation of fibrin 
and polymorphonuclear cells. The glandular layer may be en- 
tirely replaced by the fibrinous and cellular exudate, or within 
these areas a gland is still preserved here and there. This pseudo- 
membrane overlying the mucosa is composed of a network of fibrin 
enclosing multinuclear cells which often show fragmentation. !N"o 
vascularization of the membrane takes place, but a variable num- 
ber of erythrocytes are mingled with the exudate and lie free 
upon the surface. The muscularis mucosae is not always distin- 
guishable. The thickening of the gut is due chiefly to an infiltra- 
tion of the submucosa. The solitary lymph glands are also in- 
volved in the swelling and may ulcerate. As these follicular ul- 
cers only communicate with the surface by narrow fistulous tracts, 
greater portions of the mucosa may become undermined by the 
suppurative process and be cast off in toto. Hemorrhages of vary- 
ing extent are found in the submucosa in the neighbourhood of the 
muscularis mucosa?, and fibrin in the interstices of the tissues. 
The cellular infiltration does not occur uniformly, but in areas, 
being less marked in the deeper layers of the submucosa; the 
amount of fibrin and hemorrhages, on the other hand, increases in 
the deeper layers. 

The cellular exudate is uniform in character, consisting, ex- 
clusive of blood corpuscles, solely of plasma cells. These cells are 
found singly or in groups about the blood-vessels. They show the 
reticulated nucleus and fine basophilic granulations of Unna's 
plasma cells, and are without doubt identical with these. To- 
wards the muscular border these cell groups diminish in size and 
disappear entirely at the muscular coat. 

This infiltration, hemorrhage and fibrin formation may take 
place even if the mucous membrane is intact. Here lymphoid 



DYSENTERY 249 

cells are often found in addition to the cellular exudate previously 
described. The exudate is most marked next to the muscularis 
mucosae ; in the deeper layers the cells resemble plasma cells. 

The congested blood-vessels of the submucosa may be patent, 
the blood contained in them having an excess of leucocytes ; or they 
may be thrombosed, showing recent leucocytic or fibrinous throm- 
bi. The thrombosed lymph vessels are detected as large spaces in 
the submucosa containing fibrinous clots. With the exception of 
hemorrhages, which, as a rule, are trifling, the muscular coat shows 
no changes. The peritoneal coat is generally unaltered. The 
inflammatory process may terminate at any stage and recovery 
ensue. Where only small ulcerations have occurred, an atrophy 
of the mucous membrane of greater or less degree is the only per- 
manent change. Large ulcers leave cicatrices on healing, and these 
may produce more or less stenoses. Where recovery does not ensue 
the disease passes into the chronic state. 

II. Chronic Bacillary Dysentery. — In the greater part of 
the large intestines the glandular layer of the mucosa is destroyed 
either in part or completely. The deeper layers of the denuded 
mucosa and the submucosa, as well as the other intestinal layers, 
become thickened. The lumen of the gut becomes frequently 
so much diminished in size as barely to admit one finger. These 
changes are due to cell proliferation. They are most marked 
in the submucosa, the latter having a dense hyaline, almost 
structureless appearance with here and there epithelioid cells. The 
mucosa presents the remains of the crypts of Lieberkuhn enclosed 
in a reticular meshwork together with a mass of spindle and 
epithelioid cells. The blood-vessels, especially the veins, are 
markedly dilated, and there may be a formation of new blood- 
vessels. Plasma, lymphoid and eosinophile cells are found about 
the veins. 

In the muscularis the bundles of muscle cells are split up by 
newly formed connective tissue cells of an epithelioid character, 
and by an increase in the connective tissue normally present. 

III. Amebic Dysentery. — It is owing chiefly to the study of 
Councilman and Lafleur, 7 Kruse and Pasquale 21 and Kartulis, 1 
that we possess an accurate picture of the pathology of amebic 
dysentery. Kartulis claims that there is a specific character to 
the amebic intestinal ulcers which distinguishes them readily from 
those of bacillary dysentery. In contradistinction to ulcers of the 



250 DISEASES OF THE INTESTINES 

latter disease, which result from an exfoliation of the necrotic mu- 
cosa and pseudo-membrane, the lesions of amebic dysentery begin 
as an infiltration of the submucous coat which leads to necrosis 
of the overlying membrane. Purulent inflammation only exists 
when the amebse are associated with pyogenic organisms. What 
role the bacteria play in the causation of the ulcers has never been 
satisfactorily settled. From all appearances there seems to be a 
symbiosis between the amebse and bacteria, for up to the present 
time it has been impossible, as before stated, to cultivate bacteria- 
free amebse. Kruse and Pasquale, as well as Kartulis, ascribe con- 
siderable importance to this bacterial association, although they 
see in the amebse the true cause of " endemic " dysentery. The 
bacteria are found side by side with the amebse in the walls of 
the intestines and sometimes even precede them. In bacillary 
dysentery, on the other hand, although numerous cocci and bacilli 
are found in the necrotic mucous membrane, none are seen in the 
submucosa, from which it is concluded that the lesions in the sub- 
mucosa are of toxic origin. 

The solitary lymph follicles, according to Kartulis, are rarely 
involved. Kruse and Pasquale, on the other hand, consider 
them the starting-point of the inflammation. 

The surface of the mucous membrane is covered with small, 
pea-like elevations due to the abscess cavities in the submucosa. 
These small abscesses are filled with gelatinous pus, and com- 
municate with each other and the surface of the mucous mem- 
brane by narrow fistulous tracts. The opening into the intestines 
may be only the size of a pin-head, or more rarely as large as the 
cavity itself. The contents of the ulcers consist of amebse, large, 
round and swollen cells, red blood corpuscles and pus cells. The 
pathological process extends by progressive infiltration and soften- 
ing of the submucosa, followed by a necrosis of the overlying 
mucosa. 

Councilman and Lafleur describe four types of ulcers, (a) 
Cavities formed in the submucosa by purulent infiltration of a 
circumscribed focus, the cavities communicating by fistulous tracts 
with each other and the lumen of the intestine, (b) Excavated 
ulcers in the thickened submucosa with slightly undermined edges, 
(c) Ulcers with smooth edges and a clean base, (d) Ulcers cov- 
ered with incrustations. 

The secretion of the ulcers is scanty, sometimes of a purulent 



DYSENTERY 251 

character. When suppuration occurs it is always localized and is 
never found about the amebic foci. Slight deposits of fibrin may 
be found in the necrotic tissue but never as marked as in bacillary 
dysentery. 

The thickening of the intestinal coat which is most marked in 
the submucosa may attain the extreme limit of 232 mm. [!] 
(Hemmeter 55 ). 

Lesions of Other Organs: Liver. — Aside from the alterations 
in volume (enlargement or atrophy) and changes in the consist- 
ency of the liver tissue which are more or less marked in all cases, 
we occasionally find abscesses' of variable size in the parenchyma 
of the organ. These abscesses occur secondary to both bacillary 
and amebic dysentery, but are most frequently associated with the 
latter form. They present, however, certain characteristics which 
serve, as a rule, to distinguish them. 

Abscesses are of two kinds: (a) the minute pysemic abscess 
of embolic origin which is found when dysentery is complicated 
with gangrene ; (b) the dysenteric abscess proper. 

Dysenteric abscesses are classed as small, medium, and large. 
Both acute and chronic dysentery are liable to this complication ; 
the large abscesses, however, are found in chronic amebic dysen- 
tery. These abscesses may contain bacteria or amebse, alone or 
associated together, or they may even be sterile. 

According to Councilman and Lafleur there is no well-defined 
abscess wall, the liver tissue being softened and necrotic and pro- 
jecting in irregular masses into the abscess. The number of ab- 
scesses found in one case vary from a single large one containing 
400-600 gm. of pus to many small ones. Alexandre del Rio 25 says 
that in Chili it is not exceptional to obtain at the first puncture 
or opening of the abscess from 5 to 8 litres of pus. 

The contents of these abscesses is a puriform liquid, creamy 
and homogeneous, sometimes more serous in character and vary- 
ing from a reddish-yellow to a dark red chocolate colour. Micro- 
scopically we find few pus cells, fatty granules in abundance, ery- 
throcytes, necrotic liver cells, a great many amebse and sometimes 
bacteria, and cholesterin crystals. 

Lungs. — ~No specific lesions of the lungs are found. In the 
severer forms of dysentery (gangrenous) hypostatic pneumonia 
often develops. Pulmonary abscesses are due to perforation of 
an intra-abdominal abscess through the diaphragm. 



252 DISEASES OF THE INTESTINES 

Kidneys and Spleen. — Dilatation of the renal vessels and cloudy 
swelling of the tubules with commencing fatty degeneration 
is the most frequent change in the kidneys. Kelsch 56 found 
them increased in volume, congested, and presenting the char- 
acter of diffuse nephritis in some acute cases. In chronic dys- 
entery the spleen and kidneys are generally diminished in vol- 
ume and somewhat atrophied. 

Symptoms 

I. Acute Bacillary Dysentery. — The period of incubation is 
short, varying from twelve hours to three days. This stage may 
be without any symptoms, the majority of cases, however, expe- 
rience slight prodromata such as anorexia, headache, malaise, a 
feeling of distention and fulness in the abdomen and alteration 
of constipation and diarrhoea. 

The onset of the disease is marked by an increased frequency 
of the stools, accompanied by abdominal colicky pains, prostration^ 
and rise of temperature. 

a. Catarrhal Dysentery. — This is a mild form of the disease 
in which the intensity of the inflammatory symptoms is not severe 
and the constitutional manifestations are of a light character. 
The stools increase in frequency and become diarrhoeal; within 
twenty-four hours mucus is found in them. As the evacuations 
increase in number the amount of faecal matter diminishes and the 
stools assume a more mucoid character, finally consisting almost 
entirely of mucus mixed with blood. The number of dejections 
varies from six to ten in twenty-four hours. Colicky pains, pre- 
ceded by borborygmi and tenesmus, are experienced by the patient 
only at stools. The general symptoms, such as loss of appetite, 
muscular weakness and pains in the extremities, are so slight that 
the patient is frequently not confined to bed. At the end of six 
to ten days the number of stools diminishes, and they assume a more 
faecal character. Recovery is not so rapid, however, in all cases, 
remissions and exacerbations may alternate for a time so that the 
course of the disease may be protracted for a month or more. 
Other cases, again, after running a mild course for a few days, 
may pass into the severer form of the disease. 

b. Croupous Dysentery. — Without passing through a primary 
catarrhal stage the disease may assume a croupous character from 
the outset. The onset of the disease is sudden, marked by a rise 



DYSENTERY 253 

of temperature, severe colicky pains and frequent stools. With 
the first dejection there is much mucus and blood ; in subsequent 
dejections the latter ingredient rapidly increases-, until finally the 
stool consists almost entirely of pure blood. The movements num- 
ber from fifteen to twenty-five per day and are accompanied by 
violent tormina and tenesmus. The abdomen is very tender to the 
touch, especially along the course of the large intestine. Prostra- 
tion is extreme, and the patients are confined to bed. The appetite 
is poor and the emaciation becomes more marked from day to day. 
At the end of twelve to fifteen days the symptoms may abate, the 
stools become more normal in character and the patients go 
on to recovery. In some cases the patients, instead of improving, 
die at this stage of exhaustion from inanition and septic intoxica- 
tion or in consequence of a sudden collapse induced by weakness 
or severe hemorrhage. Acute dysentery, instead of running the 
continuous course just described, may be interrupted by periods 
of improvement. These remissions last eight to thirty-six hours, 
often alternating with periods of exacerbation with such regularity 
as to simulate malarial attacks in their periodicity. In this way 
the duration of the disease is considerably prolonged. 

In severe epidemics the disease often assumes a fulminating 
character. Here the symptoms are intensified, the pains are 
severer, the stools are more frequent and muco-sanguinous or 
purely sanguinous, the patient complains of chills and fever. 
The dejections may number forty, eighty, or even more in 
twenty-four hours. The skin is alternately hot and cold, the pulse 
frequent and small, prostration and general weakness are extreme. 
After four, ^.Ye or six days intestinal gangrene sets in. The stools 
resemble meat washings, and have a cadaverous odour. They con- 
tain shreds of membrane which may be microscopic in size or be 
complete casts of parts of the intestines. The sphincter becomes 
paralyzed and the rectum prolapses. The urine is scanty and con- 
tains albumen and indican. The patient now presents a picture 
similar to Asiatic cholera. As the prostration increases the ex- 
tremities become cold, the temperature falls and becomes subnor- 
mal, and the patient dies in a state of collapse and algor. 

II. Amebic Dysentery. — This may start acutely, but a dis- 
tinctly acute type has not yet been described or universally recog- 
nised. Commonly the disease begins with the ulcerative stage, an 
initial catarrhal stage being rather the exception. Nausea, bilious 



254 DISEASES OF THE INTESTINES 

vomiting and abdominal pains may precede the attack. For three 
or four days the stools are more frequent and diarrhceal in charac- 
ter. At the end of that time mucus and blood are found in them. 
The dysenteric attack proper now ensues, in which the patients, 
after considerable pain and tenesmus, pass a very small amount 
of bloody mucus. As long as ulceration has not set in the patient 
is still able to be about. At the end of a week the colicky pains 
and tenesmus increase in severity. The patients become more or 
less prostrated ; they are tormented continually by severe abdomi- 
nal pains, which are increased by the rumblings and tormina pre- 
ceding every movement. The stools are very small in amount, of 
a sanguinolent character and contain shreds of mucous membrane. 
The duration of the disease is very irregular. Recovery may set 
in after a few weeks, either spontaneously or under treatment, or 
there may be remissions in the disease (so that the patient is ap- 
parently well), followed again by exacerbations. Many cases of 
amebic dysentery tend to run a chronic course and last for years 
until terminated by some fatal complication. 

Special Symptoms. — Temperature. — Fever is not a marked or 
constant symptom. In the lighter forms of the disease it is en- 
tirely absent or only occurs as a slight febrile movement during 
the onset. In the severer types of the disease there is an evening 
temperature of 100-102°, with morning remissions which last 
during the greater part of the attack. Higher temperatures, which, 
according to Sodre, 25 never exceed 102.2° F., are generally asso- 
ciated with gangrenous processes in the intestines. 

In amebic dysentery the temperature may reach 104°, return- 
ing to normal in four or Rye days (Hemmeter 55 ). As a rule ame- 
bic dysentery runs an afebrile course. Continued high fever for 
a week or more is noted in more severe cases or where some ab- 
dominal viscus has become secondarily involved. In fatal cases the 
temperature may become subnormal before the end. 

Symptoms Referable to the Abdominal Viscera. — Vomiting. 
— Nausea and vomiting may precede the attack or occur during 
the course of the disease. The vomited matter is either bilious 
or consists of large quantities of yellowish serum; in some cases 
it is due merely to errors in diet and is then readily controlled by 
regulating the latter. Where emesis is associated with diarrhoea 
the attack resembles cholera morbus; in these cases, especially if 
the emesis persists after the stools take on a dysenteric character, 



DYSENTERY 255 

the outcome is speedily fatal. Vomiting is not limited to the be- 
ginning of the disease. Hemmeter (1. c, p. 550) regards the 
emesis as due mainly to a " sympathetic gastritis/' although also 
admitting a type due to autointoxication. 

Pain. — In mild cases or during the initial stage of the disease 
pain is comparatively slight and of a colicky nature. When ulcer- 
ation has set in the spasmodic contractions and the distention of 
the inflamed bowels give rise to excruciating agony, relieved only 
by the passage of gas and the little blood-stained mucus which con- 
stitutes the stool at this time. If the inflammation is in the colon 
near the rectum or in the small intestine, considerable time may 
elapse before these tormina are relieved by an evacuation of the 
bowels. The abdomen, moreover, becomes exquisitely tender, so 
that even the pressure of the bed-clothes becomes unbearable to the 
patient. The latter assumes the dorsal decubitus with the thighs 
flexed on the abdomen, similar to the position assumed in acute 
peritonitis. 

Tenesmus is experienced as soon as the stool has become fre- 
quent, and in severe cases it is almost continuous. If the sigmoid 
flexure and rectum are inflamed, the smallest particles of faecal 
matter are sufficient to set up a violent tenesmus. In cases with 
a fatal termination pain ceases towards the end ; the intestines 
and sphincter ani become paralyzed from the continual contrac- 
tion or possibly from toxic absorption, and the mucous membrane 
protrudes through the relaxed sphincter. In children prolapse of 
the rectum is found even in comparatively mild cases. 

Bladder. — The inflammation of the bowels may cause a hyper- 
£emia or even an actual inflammation of the vesical mucous mem- 
brane about the neck of the bladder, so that the patients suffer 
from strangury and vesical tenesmus. The strangury may be 
severe enough to necessitate the use of a catheter. 

Complications arising in the course of the disease can be 
classed either as local (viz., necrosis of portions of the bowels, ap- 
pendicitis, perforation and peritonitis), or those due to metastatic 
inflammation of microbic or toxic origin. The latter class com- 
prises abscesses of the liver, spleen, parotid gland, brain and lung, 
inflammation of joints, and various forms of paralyses and neuri- 
tides. 

Only a few cases of appendicitis due to dysentery have been 
reported. Vandenbossche 5T gives the history of a case of a French 



256 DISEASES OF THE INTESTINES 

soldier in China who had been sick with dysentery three weeks 
and who died of a gangrenous dysenteric appendicitis. The ap- 
pendicular inflammation is simply an extension of the dysenteric 
process from the caecum to the appendix. Josue 58 and Beausse- 
nat 59 have shown experimentally that the lesions of the large 
intestine can extend to the appendix. 

Peritonitis. — Sodre considers this the most frequent compli- 
cation of dysentery. It may occur even without perforation of the 
intestines. Where deep ulcerations exist, especially if the mus- 
cularis is involved, the numerous lymph radicles of the intestines 
are laid bare and bacteria can be readily carried through the 
lymph-channels to the peritoneum. Woodward (loc. cit., p. 388) 
sees in the hyperemia of the peritoneum, which is observed with 
deep ulcerations, a cause of peritonitis. The plastic exudate 
which is thrown out by the inflamed peritoneum causes adjacent 
coils of intestine to become adherent. Clinically, this plastic 
peritonitis is characterized by localized points of tenderness and 
continuous pain. 

Perforation occurs most frequently in gangrenous and in 
chronic bacillary dysentery. In chronic amebic dysentery the 
reaction of the tissues to the inflammation produces a thickening 
so marked as practically to preclude this possibility. Perfora- 
tions may occur either gradually or suddenly. In the former case 
a localized peritonitis is produced which generally results in an 
encapsulated abscess. The symptoms are identical with those of 
an appendicitis abscess (viz., rigidity, pain, tenderness and tu- 
mour) ; in fact, since perforation has been found to occur most fre- 
quently in the cecum it is not always possible to distinguish them. 
When perforation occurs suddenly, a generalized peritonitis is al- 
ways the result unless prompt surgical interference is resorted to. 
Although in recent years many successful operations have been 
performed for intestinal perforations in typhoid fever, it is doubt- 
ful whether similar brilliant results can be achieved in cases where 
the ulcerative processes are more extensive and of longer duration 
and the intestinal walls thickened as in dysentery. The physical 
signs are the same as of perforation in typhoid fever, the diagnosis 
can, however, be more readily made since the question of hemor- 
rhage need not be taken so largely into account. Dysentery being 
afebrile as a rule during the later stages of the disease when per- 
foration occurs, the sudden and marked elevation of temperature 



DYSENTERY 257 

following an attack of severe localized abdominal pain together 
with symptoms of collapse (pallor, coolness of extremities and 
rapid, thready pulse), the tympanites and disappearance of liver 
dulness cannot fail to lead one to the correct diagnosis. 

In chronic dysentery large serous effusions often persist in the 
abdomen for a long time after all enteric symptoms have subsided. 

Hemorrhage. — Although copious hemorrhages such as are ob- 
served in typhoid fever do not occur, the continued loss of even 
moderate amounts of blood in acute cases is sufficient to bring on a 
fatal termination in those individuals who are already exhausted 
by the duration of their disease. 

Abscess of the Liver. — An idea of the comparative frequency 
of this complication in bacillary and amebic dysentery can be 
gained from the statistics collected by Kartulis. 1 Among 47,900 
cases of amebic (endemic) dysentery collected by various observ- 
ers in the tropics, abscess of the liver occurred 957 times (20 per 
cent.). In bacillary (epidemic) dysentery, on the other hand, this 
complication occurred only thirty-six times in 474 cases (about 
7. 6 per cent. ) 

Pulmonary abscess may occur in conjunction with hepatic ab- 
scesses, although infrequently. The infection takes place either 
directly through a gradual perforation of the abscess through the 
diaphragm, or indirectly by means of the lymphatics. 

The liver abscess is located most frequently in the right lobe 
near the upper or posterior surface. It is characteristic that the 
increase in the size of the liver generally occurs upward towards 
the thorax, so that the liver dulness is highest in the axillary line 
and lowest towards the spinal column. The lower border of the 
lung shows diminished respiratory mobility (Pel 60 ). This sign 
can be demonstrated by percussion or ad oculos (Litten's dia- 
phragmatic sign). Enlargement of the liver does not always oc- 
cur, not even if numerous abscesses are found in the substance of 
the organ. Superficial abscesses, or those occurring exceptionally 
in the left lobe of the liver, can be palpated as rounded promi- 
nences. Pain, according to Chvostek, is absent in one quarter of 
the cases. Where it does occur it may be sharply localized and is 
often associated with characteristic pains in the right shoulder. 
Enlargement of the spleen only occurs where the liver abscess is 
part of the symptom-complex of a septico-pysemia. When the 
symptoms point to an affection of the liver, the presence of fever 



258 DISEASES OF THE INTESTINES 

is of great diagnostic importance. Leube 61 says, " Excepting the 
febrile movements which occur in cancer of the liver and in chole- 
lithiasis, acute yellow atrophy is the only disease of the liver asso- 
ciated with temperature from which an abscess must be differen- 
tiated." Jaundice, ascites and gastric disturbances are not of fre- 
quent occurrence. Abscess of the liver may terminate either in a 
spontaneous cure by perforation into the stomach, intestines or 
externally ; or it may lead to the formation of a subphrenic ab- 
scess, an abscess of the lung, empyema of the chest, general peri- 
tonitis, or local or general sepsis. The physical signs and symp- 
toms of these various complications need not be considered here, as 
they are sufficiently well discussed in text-books on surgery. 

Abscess of the brain occurs only exceptionally. Abscess of the 
spleen was observed only once by Kartulis. 

Arthropathies. — It has been known for a long time that dysen- 
tery may be associated with articular manifestations. Trousseau 
describes a " rheumatic form of the disease," and a certain re- 
lation between rheumatism and dysentery was admitted by many 
of the French school. 

Most frequently dysenteric arthritides appear during convales- 
cence, though they may occur as well during the first and second 
weeks of an acute dysentery. Poly- as well as monarticular forms 
occur. The symptoms subside with the dysentery, or more rarely 
a stubborn affection of one or two joints persists a long while after 
all enteric symptoms have subsided. Local elevations of tempera- 
ture, redness and exudation into the synovial sac, do not occur; the 
periarticular tissue becomes tumefied, there is dull pain without 
any exacerbation ; ankylosis and suppuration do not occur. 

Thrombosis. — Cases of thrombosis have been recorded by Lav- 
eran in 1885 (femoral thrombosis, and thrombosis of the venous 
sinuses of the brain), and by Cambay (thrombosis of left iliac 
artery). Since then additional cases have been reported. These 
thrombi are either marantic, occurring in chronic dysentery or 
during convalescence, or else are of septic origin, developing in 
the course of an acute dysentery. 

Anasarca. — Hospel, Canteloupe and Cambay consider this 
one of the sequelae of dysentery. It does not occur frequently, and 
is an indication of the hydrasmic condition of the blood rather than 
a serious lesion of any organ such as the kidneys, etc. 

Myelitis and Neuritis. — Little is known concerning the nerve 



DYSENTERY 259 

lesions complicating dysentery. Woodward (loc. cit., p. 410) in 
his extensive statistics on dysentery mentions only one case of 
paralysis following acute dysentery. S. Weir Mitchell, 62 on the 
other hand, claims to have encountered many cases of paraplegia 
following both acute and chronic dysentery. The nerve lesion 
evidences itself as a paraplegia of the extremities or exception- 
ally as a hemiplegia, the amount of disability varying from a 
slight paresis to an absolute paralysis. Pain may or may not be 
present. 

Concerning the pathology of these affections there is no una- 
nimity of opinion, v. Leyden considers the lesion an ascending and 
descending neuritis, whereas other observers look upon it as a tox- 
aemia or as a myelitis due to an extension of the infectious process 
through the venous channels. 

Examination or the Faeces, Urine and Blood 

Fceces. — The characteristic dysenteric stools are preceded as a 
rule by loose movements, diarrhceal in nature. These evacuations 
are small in amount, thin and watery or grumous, bile-stained, 
and containing yellow flocculent masses. During the acute state 
of the disease the dejections consist either entirely of mucus 
stained with blood or in admixture with faecal material. In the 
later stages the stools have the appearance of meat washings con- 
taining mucus as flocculi or as sago-like grains. Bloody stools, 
either red or, if decomposed, of a chocolate colour, may alternate 
with the preceding or predominate almost entirely. In gangre- 
nous dysentery the stools have an extremely offensive cadaverous 
odour; they are watery and serous, dark-brown or reddish-brown in 
colour, and contain an abundance of necrotic tissue. 

Woodward (loc. cit, p. 353) classifies the constituents of the 
stools as follows: (1) feculant material; (2) mucus, pus, and com- 
binations of the same; (3) blood and bloody serum; (4) portions 
of pseudo-membrane and necrotic intestinal tissue; (5) bacteria 
rhizopods, amebae and other parasites; (6) accidental matters de- 
rived from medicines and injecta. 

(1) The amount of faecal matter found varies with the sever- 
ity of the inflammation. When the dysenteric attack has been pre- 
ceded by diarrhceal movements, no faecal matter at all is found at 
the height of the disease ; in cases of preceding constipation, how- 



260 DISEASES OF THE INTESTINES 

ever, small scybalous masses are passed continually. Recovery is 
always presaged by the reappearance of faecal matter in the stool. 

(2) Mucus occurs as translucent tenacious masses or grumous 
flakes (frog-spawn), varying from pure white to a yellowish colour; 
later on the translucency disappears and the mucus becomes 
opaque and grayish. The stringy quality, which is very marked 
at first, also disappears entirely so that the mucus becomes readily 
miscible with water. Pus in small quantities can only be recog- 
nised microscopically; when present in large amounts it has a 
characteristic penetrating odour. 

(3) The tarry stools due to decomposed blood such as are 
found in ulcers of the stomach, duodenum, etc., are rarely encoun- 
tered; the blood can easily be detected by its bright red colour. 
Usually great amounts of blood are not lost, the blood-stained serum 
which is passed in large quantities being merely an exudate from 
the intestinal mucosa. Niemeyer 63 and others have shown that 
this albuminous fluid which can be demonstrated abundantly by the 
ordinary tests in the dejections, is not due to the admixture of 
blood with the stools. Very few blood corpuscles are found, and 
consequently it may be regarded as a genuine transudation of 
blood plasma. Woodward believes that the collapse which is ob- 
served in the choleraic type of dysentery is exactly analogous. 
The alkaline reaction of the dysenteric stools is due in part to the 
presence of this serum, but can also be accounted for by the alka- 
line fermentation of the intestinal contents. 

(4) Pseudo-membranes and necrosed intestinal tissue. — Diph- 
theroid membranes are found only in the stage of croupous inflam- 
mation and after ulceration has set in. Characteristic membranes 
composed of a network of fibrin enclosing cells and blood corpus- 
cles do not occur in amebic dysentery, the slough consisting in 
these cases almost entirely of the dead mucous membrane. The 
separation of the membrane together with the underlying portion 
of intestinal mucosa and submucosa is analogous to the separation 
of bone sequestra. Through the necrobiosis of the cells of the mu- 
cosa or submucosa the organic continuity of the tissues is dissolved, 
and a line of demarcation is established between the dead and liv- 
ing tissues; when this process is complete the sphacelus is 
cast off, leaving a more or less extensive defect. Microscopically we 
can recognise almost pure fibrinous membranes or those contain- 
ing also portions of the intestinal wall. It is often possible to rec- 



DYSENTERY 261 

ognise from what, layer of the intestinal coat the slough is derived, 
by the characteristic cells of the various coats. When, however, 
necrosis has been complete, we find nothing but a mass of granular 
detritus with a little fibrin and some blood corpuscles. These 
membranes vary from microscopic size to several inches in length. 
In gangrenous stools the fragments are entirely necrotic and un- 
recognisable. 

(5) Bacteria, amebse and other parasites. — The characteristics 
of the different bacteria and varieties of amebse which are now con- 
sidered to be the cause of dysentery have been sufficiently dis- 
cussed under the heading of bacteriology. There are, however, a 
number of intestinal parasites which are occasionally found in 
cases presenting the clinical features of dysentery. The tricho- 
monas intestinalis, cercomonas hominis, coccidia, balantidium 
coli, megastoma entericum, distoma haematobium, Bilharzii, and 
the anguilulla intestinalis 6i have all been described in cases pre- 
senting symptoms of an acute colitis. 

(6) Ingesta and alteration of stools due to drugs. — Specific 
discolorations of the stool occur after the use of certain drugs ; thus 
bismuth gives a black and calomel a green colour. On the whole 
this is of small clinical importance ; occasionally, however, it may 
be necessary to distinguish the tarry stools of hemorrhage from 
the black stools of bismuth. Microscopical examination or Teich- 
mann's blood test will readily disclose the true state of affairs. 

The action of the digestive ferments being much diminished 
and the intestinal peristalsis being increased, food detritus which 
is but little changed is found in the stools. Hemmeter claims 
that the fat which has been described as occurring in dysenteric 
stools is due entirely to lientery, and disappears by excluding 
fat from the dietary. 

The urine is generally diminished in quantity and of a high 
specific gravity ; the amount of urea and uric acid is increased and 
the chlorids diminished; bile pigment is sometimes found. In 
moderately severe cases the urine contains some albumen ; casts 
and renal epithelium are found only exceptionally in the severest 
forms of the disease. Indican occurs generally in traces, but be- 
comes marked where peritoneal complications have set in. An 
appreciable reduction of urea occurs at the height of the disease. 

Blood. — Quantitative and qualitative changes in the corpuscu- 
lar elements and in the composition of the blood plasma are no- 
18 



i" 12 DISEASES OF THE INTESTINES 

tieed during the course of the disease, and are often of service in 
the diagnosis of complications such as intestinal perforation, peri- 
tonitis, abscess of the liver and other viscera, etc. There is. how- 
ever, nothing pathognostic in these blood changes which would 
warrant a recapitulation. 

It is due to the investigations of Shiga 2b that a specific serum 
reaction of the blood in bacillary dysentery similar in all respects 
to the Gruber-Widal reaction of typhoid fever has been discovered. 
Shiga found that the sera of dysenteric patients, even when much 
diluted, agglutinated pure cultures of the bacillus isolated by 
him from cases of epidemic dysentery in Japan. 

According to Shiga there is a direct relationship between the 
severity of the symptoms and the strength of the serum reaction. 
" In most cases after a week or ten days, dilutions of one part of 
serum to thirty of water gave agglutination, and often one part to 
fifty or more. In a few cases only, a concentration of one to ten 
parts was required. A very few gave no reaction when one part 
of serum was added to ten of water. The dilution was made with 
fluid blood or with serum. With persons who had no dysentery, 
no serum reaction was obtained, but with convalescents reactions 
remained over a varied length of time, in one case as long as eight 
months. 

" The reaction was more marked in the more severe cases, 
usually a dilution of one part to fifty giving a reaction in these. 
In cases of moderate severity, reaction was obtained as a rule in 
dilutions between one to fifty and one to twenty parts. In the 
mildest cases, when only a little mucus was noticed in the stool, 
the agglutination was. as a rule, hardly noticeable. Sometimes in 
the quickly fatal cases it did not appear at all before death. In 
enteric cases the agglutination usually begins in from three to 
five days, reaches the highest point at beginning convalescence, 
and then gradually lessens. In rare cases it may not occur until 
convalescence has been established." 

Cases of chronic bacillary dysentery also show this reaction, 
but the results are more variable. In several cases of amebic dys- 
entery which were treated at the Johns Hopkins Hospital, the 
blood serum failed to produce the reaction with the bacillus ob- 
tained in Manila (Osier, cited bv Tlexner * 3 ). These observations 
of Osier have been confirmed by other investigators, and it seems 
very likely in view of this testimony that in the serum reaction of 
dysentery we have not only a specific test for the disease, but also 



DYSENTERY 263 

a means of differentiating the baeillary from the amebic form of 
the disease. 

In subsequent epidemics in Manila and the United States 
which were studied in respect to the serum reaction, slight varia- 
tions in the appearance of the reaction and the amount of dilution 
ssible, were observed. It was found that cultures of Shiga's 
bacillus and Flexner's Manila bacillus were not agglutinated alike 
by all sera. Those sera which agglutinated the Plexner bacillus 
in dilutions of one to one thousand and one to two thousand, even 
in greater concentrations produced no reaction or only par- 
tial reaction with the Shiga bacillus. There can be little 
doubt, therefore, that Shiga's bacillus and Flexner's Manila bacil- 
lus, although showing many points of similarity, are nevertheless 
different varieties. In the epidemics which have been studied at 
Manila and in the United States ( Seal Harbor. Baltimore. Tucka- 
hoe, etc. ) , specific agglutins were found either for the Shiga or 
the Fiexner bacillus : in some cases the sera agglutinated both 
varieties, but the reactions were always mere marked for one or 
the other variety. 

It is a question whether both bacilli may not occur in the same 
epidemic and even in the same individuals. Park anel Carey K 
-ay. u It seems to us that it is extremely probable that Shiga, if 
he carries his cultural and agglutination tests as far as is now 
known to be necessary in order to differentiate the difierent vari- 
eties, will find that in Japan, as well as in America and elsewhere, 
not one. but several varieties of this group of bacilli are present. " 

DIAGXOSIS 

Although, during the prevalence of an epidemic, the diag- 
nosis of dysentery can be made without difficulty from the 
general symptomatology which has already been discussed at 
length, the mild sporadic cases which occur from time to time 
present such similarity to the simple non-infectious inflammations 
of the colon and rectum that an absolute diagnosis is out :£ the 
question. TThere a serum reaction can be obtained there need be 
no farther doubt on the subject, but. as has been previously pointed 
out. it is just in the mild cases that there is no. or only partial, 
agglutination of the bacilli. 

The cultivation of the dysentery bacillus from the steels can 
only be carried out with considerable difficulty and in large lab- 
oratories. Park and Dunham M sdve the following directions : 



264: DISEASES OF THE INTESTINES 

" To obtain the Shiga bacillus, proper dilutions of the faeces 
are made, and the cultures put in the incubator at 37-38° C. for 
eighteen hours. The plates are then inspected and the smallest of 
the colon-like colonies are ' fished ' and from them glucose-agar 
tubes are inoculated. The visible colonies may then be marked by a 
spot on the Petri dish opposite to them, and the plates put in the 
incubator for another eighteen to twenty-four hours. Vedder and 
Duval found that when Shiga bacilli were present in the stools in 
any quantity, some colonies of the Shiga bacillus were almost cer- 
tain to develop in the second twenty-four hours, while as a rule 
all colon bacillus colonies would develop before that time. The 
late-appearing colon-like colonies were therefore inoculated into 
glucose-agar tubes. The bacilli which produced visible gas in the 
giucose-agar were excluded, while the others were tested in a high 
dilution of a specific Shiga bacillus agglutinating serum. The ab- 
sence of gas in cultures in glucose media, the suitable size and ap- 
pearance of the bacilli in the hanging drop, together with the pos- 
itive agglutination reaction, are considered sufficient to identify 
the bacillus in any epidemic when one or two cultures of earlier 
cases have been worked out." 

Cancer of the Rectum with the symptoms of severe and fre- 
quent attacks of tenesmus and evacuations of scanty blood-stained 
mucus may simulate dysentery. But the gradual development of 
the dysenteroid symptoms preceded for several months by consti- 
pation and lumbar pains always creates suspicion of a malignant 
neoplasm. Digital examination or proctoscopy generally reveals 
the presence of the tumour. 

Hemmeter 55 points out that membranous colitis may occa- 
sionally be confused with epidemic dysentery of the diphtheritic 
variety. The subjects of this disease are generally neurasthenic 
or hysterical patients. 

" The discharge may even be accompanied by feculent, watery, 
bloody, or muco-purulent stools. The membranous substances dis- 
charged in this form of colitis are composed chiefly of thickened 
mucus, which dissolves freely in a solution of potassium hydroxid, 
but does not dissolve in dilute acetic acid. The membranes, when 
examined microscopically, consist of a hyaline or slightly granular 
substance, containing a few cells resembling white corpuscles. Oc- 
casionally they contain the columnar epithelial cells of the surface 
epithelium of the intestines. The stools of diphtheritic dysentery, 



DYSENTERY 265 

as has been emphasized repeatedly, are composed of granular 
fibrin." The prevalence of other cases of " bloody diarrhoea " and 
the serum reaction of the blood or the presence of amebae in the 
stools, will establish the identity of dysentery in doubtful cases. 

In chronic amebic dysentery, the presence of the amebse in the 
stools and the typical ulcers in the rectum or sigmoid flexure serve 
to establish a correct diagnosis. In the chronic bacillary form of 
the disease, when the serum reaction is absent, the history of the 
case is the only guide. 

Prognosis. — The mortality of acute dysentery varies greatly 
in the different epidemics, and depends on the virulence of the in- 
fection, as well as on the care (sick-room hygiene, sanitation, diet, 
etc.) which can be devoted to the patients. Much is to be hoped 
from the recent advance in our knowledge of the etiology as well as 
from the favourable results reported through the use of serum. 
Serious complications, viz., liver abscess, perforative peritonitis, 
etc., always render the outcome exceedingly dubious. Sporadic 
cases are as a rule mild and may recover without any treatment. 
The gangrenous form of dysentery is invariably fatal. 

Chronic dysentery, unless complicated, rarely affects the gen- 
eral health of patients. 

Under suitable dietetic and other careful treatment recovery 
has ensued after many years. Much is also to be hoped for in this 
class of patients when serum therapy will have been more thor- 
oughly investigated. 

Teeatmekt 

The hygienic rules, dietary, and treatment are conducted along 
similar lines in the bacillary as well as the amebic form of dysen- 
tery. It is of primary importance to bear in mind the infectious 
nature of the disease. Proper isolation of the patient must be se- 
cured and prophylactic measures instituted to prevent or limit the 
spread of the infection. The transmission of the disease, accord- 
ing to our present knowledge, occurs principally through con- 
tamination with infected fseces ; the same precautionary measures 
which are instituted in typhoid fever should be applied here.* 

* In typhoid we have learned to recognise that the blood and the urine may 
also be sources for the spread of the infection. It would therefore be highly im- 
portant to ascertain whether this is true as well of dysentery. 



266 DISEASES OF THE INTESTINES 

The possibility of the disease being auto-innoculable must be re- 
membered, and it would be well to have patients who are able to 
feed themselves always disinfect their hands before eating. These 
precautions are especially necessary in army camps, and under any 
conditions where there is crowding together of people. 

In acute cases, patients should be put to bed and kept there 
until a marked remission in the severity of the symptoms occurs. 

Diet. — This should present little difficulty in cases of moderate 
severity or of short duration; in protracted cases it is not an easy 
task to sustain the strength with suitable alimentation. The diet 
should serve a twofold purpose : to yield sufficient nourishment to 
the patient, and to check the excessive number of evacuations. A 
secondary, but important, object is to replace as far as possible the 
large amount of fluids lost with the discharges. 

The food selected should be bland, non-irritating, causing little 
intestinal fermentation and leaving the smallest amount of resi- 
due. The exact diet will vary with the number of evacuations. 
Since the small intestine is rarely actively involved, intestinal 
digestion and absorption can proceed provided we are able to re- 
tard peristalsis. 

With regard to the use of milk in dysentery there is still a di- 
versity of opinion. C. A. Ewald 6T considers it as a rule unsuit- 
able, as it increases the pain and tenesmus and produces fulness in 
the epigastrium and vomiting. He maintains that it should be 
used during convalescence, and during the acute stage only as an 
addition to glutinous soups. Hemmeter, 55 on the contrary, al- 
though admitting that milk sometimes fails, has found in a large 
number of cases treated by him that it was eminently suited to 
the needs of his patients. 

If given at all, milk should be given in small quantities at a 
time, the total amount for twenty-four hours not to exceed one to 
two litres. If large curds appear in the stools the milk should be 
discontinued. 

The addition of a cereal decoction is very useful to break up 
the curd; lime water, too, serves a like purpose and has besides 
an astringent effect. Where a strong aversion to milk exists, the 
addition of coffee, tea, cocoa, brandy, etc., is recommended. If 
the diarrhoea is marked, it is better not to continue with milk, but 
to substitute cocoa and tea without milk, both being valuable on 
account of their astringent properties (tannin). 



DYSENTERY 267 

A diet consisting of cereals or amylaceous food answers in 
many cases. Gruels prepared from barley, oat-meal ( ?), farina, 
rice, sago, tapioca, etc., or mucilaginous soups of the roots of va- 
rious plants, such as salep, arrow-root, etc., are not only tolerated 
but act as demulcents to sensitive mucous membranes. 

Albuminous food cannot be dispensed with entirely, especially 
in severe and protracted cases. Broths (beef, mutton, chicken, 
etc.) may be given with perhaps the addition of a small amount 
of cereals or the white of eggs ; the latter may also be administered 
as albumin-water. Whole eggs may also be tried, either raw, soft 
boiled or hard boiled (if finely divided before ingestion), but as 
they are not always well borne they may have to be discontinued. 
Some variation in the diet is found in the colloid food-stuffs, viz., 
calves'-foot jelly, etc. 

The liquid diet in part replaces the fluids lost with the evacua- 
tions; in addition, stimulants (brandy, red wines rich in tannin, 
as Camarite, old Bordeaux, Hungarian, etc.) may be given, either 
pure or with the addition of water. In the tropics alcoholic bev- 
erages are not well tolerated. 

When the stools become firm we may return to solid food. 
Scraped beef, finely minced chicken, squab, ham, etc., tender fish 
and the like should be given in small quantities, and increased gradu- 
ally if tolerated. Plenty of good butter and starchy vegetables in 
mashed form and a larger number of eggs may now be given. 

Medicinal Treatment. — When seen early, an initial dose of 
calomel or castor oil, or, perhaps better still, of a saline cathartic 
should be given. This at once relieves the bowel of any possibly 
contained irritant or decomposing contents, as well as of consider- 
able of the disease organisms present. If necessary later, the dose 
may be repeated. Usually, however, laxatives are not given in 
the later stages of the disease. If severe colicky pains be pres- 
ent, relief is frequently obtained by the external application of 
dry or moist heat (hot-water bag, fomentations, poultices, etc.). 
Should these fail, morphin, hypodermically, may be given. This 
drug has the additional advantage of allaying peristalsis. 

Ipecac has been regarded almost as a specific remedy by An- 
glo-Indian physicians, the French colonial physicians, and in South 
America. Kartulis 1 considers it the drug par excellence in bacil- 
lary dysentery, although he, too, admits that in severe forms as 
well as in the amebic form it is ineffectual. The usual treatment 



268 DISEASES OF THE INTESTINES 

consists in administering large doses (20 grs.) of powdered 
ipecac root in the form of a decoction, preceded by an injection of 
morphin to prevent emesis. In the hands of Osier, 68 Woodward, 26 
and Hemmeter 55 no markedly good results were seen; on the con- 
trary, the extreme nausea, vomiting and profuse diarrhoea have 
caused them to abandon the method entirely. 

A variety of intestinal antiseptics of the phenyl group (salol, 
naphthol, /3-naphthol, etc.) have been used, but without much 
benefit. 

The salts of bismuth, and the vegetable astringents as tannal- 
bin, tannigen, etc., either alone or in combination with each other, 
are often of much service and possess the added advantage of not 
being deleterious. 

Enteroclysis. — The most rational plan of medicating the in- 
flamed intestinal mucosa is by irrigation of the colon. This can be 
accomplished with an ordinary fountain syringe, the patient being 
placed either in the dorsal or left lateral position, with the hips 
elevated. When it is desired to irrigate the bowel in the neighbour- 
hood of the cecum, the knee-chest position must be used, or the pa- 
tient should be turned from the left lateral position to the right 
after the fluid has been introduced. Kemp's rectal tube or a soft 
rectal tube may be used. The irrigator should be held two to five 
feet above the level of the outflow tube, and the irrigations con- 
tinued until the return flow is clear. This should be done once or 
twice a day, and if necessary in collapse or great depression small 
saline enemata (§vj to oviij) may be given in the interval. When 
great pain or irritability of the rectum and sphincter ani exists, 
these parts should be anaesthetized with a cocain or orthoform 
solution, or an analgesic ointment applied before commencing 
the irrigation. 

The irrigations serve to flush out the bowel, to stimulate the 
patient and to replace in part body fluids lost; they may consist 
of plain boiled water or normal salt solution (101-105° F.). The 
addition of TTI y-x oil of peppermint or oil of cinnamon to the pint 
of normal salt solution relieves the flatulence (W. H. Thomson). 
No good results are accomplished by the use of strong antiseptic 
solutions (corrosive sublimate, silver nitrate, etc.) ; they may even 
do harm. Solutions of tannic acid (0.5 per cent.) and suspensions 
of bismuth tend to reduce the inflammation and check the bloody 
diarrhoea. 



DYSENTERY 269 

In amebic dysentery, irrigations with quinine sulphate, 1 to 
1,000, are said to destroy the amebse in about four days. 

Serum Therapy. — Shiga found that by inoculating horses with 
a twenty-four-hours' old culture of B. dysenteries which had been 
previously raised to 60° C, an antitoxic serum could be derived 
from the blood. 

The results obtained by Shiga with this antitoxin surpassed all 
other methods of treatment. "Whereas formerly the mortality 
varied from 22 to 55 per cent., with the use of the antitoxin it was 
reduced to 8.5 to 12.5 per cent. 

The following rules are used in administering the serum at 
the Institute for Infectious Diseases in Tokio : 

1. In mild cases the serum is inoculated once in a dose of 
6 to 10 c.c. 

2. In cases of medium severity the serum is twice inoculated 
in doses of 10 c.c. The interval is from six to ten hours. 

3. In severe cases the greatest quantities of serum are inocu- 
lated (about 60 c.c). The daily dose does not, however, exceed 
20 c.c. 

In its incipiency the disease is speedily cured, and in the 
more advanced stages the symptoms are speedily ameliorated and 
the number of stools markedly diminished. 

For rational administration of a dysentery antitoxin it will 
be necessary to secure antitoxin for each variety of dysentery 
bacillus, and to determine by a Gruber-Widal reaction in each pa- 
tient which antitoxin is required. 

Chronic Dysentery. — During the exacerbations the treatment 
is the same as during acute attacks. In the interim great attention 
should be paid to the diet. Such articles of food as are allowed 
during convalescence with the addition of light roast or broiled 
beef, and vegetables of finer texture, afford sufficient variety and 
sustenance to the patient. 

Chronic ulcers when low enough in the rectum to be seen 
should be touched with silver nitrate and all pockets slit open. 
With ulcerations higher up irrigations with silver nitrate, 1 to 
1,000, gradually increased in strength to 1 to 250, should be 
practised every day or every second day. 

In cases where this treatment proves ineffectual, appendicos- 
tomy as proposed by Weir 69 combined with irrigations may often 
effect a complete cure. 



270 DISEASES OF THE INTESTINES 



LITERATURE 

1. Kartulis. Virchow's Archiv, 1885; Dysenterie, Bd. v, Abth. iii ; Noth- 

nagel's spec. Path. u. Therapie. Wien. 1896. 

2. Hirsch. Handb. der historisch-geographischen Pathologie, Bd. ii. 
8. Loesch. Yirchow's Archiv, Bd. lxv, 1875. 

4. Epstein. Prager med. Wochenschr., 1893, p. 38. 

5. Hlava. Zeitschr. f. boehm. Aerzte in Prag, 1887. 

6. Osier. Johns Hopkins Med. Bull., vol. i, 1890, No. 5. 

7. Councilman and Lafleur. Johns Hopkins Hosp. Rep., vol. ii, 1891, pp. 

395-548. 

8. Simon. Johns Hopkins Hosp. Bull., 1890. 

9. Nasse. Deutsche med. Wochenschr., 1891, p. 81. 

10. Musser. University Med. Mag., 1890, vol. iii. 

11. Eichberg. Med. News, 1891, No. 8, p. 201. 

12. Dock. Daniel's Texas Med. Journal, 1891, pp. 419-431. 

13. Stengel. Phila. Med. News, 1890, p. 500; Univ. Med. Mag., Jan., 1892. 

14. Lutz. Centralbl. f. Bact. u. Parasitenk., 1891, Bd. x. No. 8. 

15. Calandruccio. Atti dell' Accad. Gioenia, Series iv, vol. ii, 1890, p. 95. 

16. Vivaldi. La riforma medica, 1894, No. 238. 

17. Fenoglio. Arch, italiennes de medecine, T. xiv, 1890, pp. 62-70. 

18. Massiutin. Wratsch, 1889, No. 25. 

19. Cahen. Deutsche med. Wochenschr., 1891, p. 53. 

20. Pfeiffer. Die Protozoen als Krankheitserreger. Jena, 1891, 2te Aufl. 

21. Kruse u. Pasquale. Deutsche med. Wochenschr., 1893, pp. 54 and 378; 

Zeitschr. f. Hygiene, 1894, pp. 1-148. 

22. Lobas. Wratsch, 1894, No. 30, p. 845. 

23. Kovacs. Zeitschr. f. Heilkunde, Bd. xiv, 1893, p. 165. 

24. Baelz. Berl. klin. Wochenschr., 1883. p. 237. 

25. Cited by Sodre. Twentieth Century Practice of Medicine, vol. xvi, 1st 

edit. 

26. Woodward. Medical and Surgical History of War of the Rebellion, vol. ii. 

27. Gemmel. Idiopathic Ulcerative Colitis (Dysentery), London, 1898. 

28. Shiga. Centralbl. f. Bacteriol. u. Parasitenk., 1898, vol. xxiv, pp. 879 

and 913. 

29. Klebs. Cited by Flexner; see ref. 43. 

30. Prior. Ibidem. 

31. Ziegler. Handb. d. spec. path. Anatomie, 7th edit., 1892, p. 544. 

32. Chantemesse et Widal. Bullet, de l'Acad. de medecine, T. xxx, 1888, 

p. 522. 

33. Arnaud. Annal dTnst. Pasteur, 1894, No. 7, p. 495. 

34. Celli e Fiocca. La riforma medica, 1894, p. 435; Centralbl. f. Bact. u. 

Pathol., Bd. xvi, p. 329; ibid., Bd. xvii, p. 309, etc. 

35. Escherich. Die Darmbakterien d. Sauglings, u. ihre Beziehung zur 

Physiol, der Verdauung. Graz, 1886. 

36. Ogata. Centralbl. f. Bact. u. Pathol., Bd. ii, 1892, p. 264; ibid., Bd. xiv, 

1893, p. 165. 



DYSENTERY 271 

37. Zancarol. Le progres med., 1895, No. 24, p. 393. 

38. Sylvestri. La riforma medica, 1894, IS r o. 22. 

39. Bertrand et Bauscher. Gaz. hebdom., 1893, No. 40, p. 474. 

40. Ascher. Deutsche med. Wochenschr., 1899, No. 4. 

41. Calmette. Cited by Flexner; see ref. 43. 

42. Lartigau. Jour, of Exper. Med., vol. iii, p. 595. 

43. Flexner. On the Etiology of Tropical Dysentery. Middleton-Goldsmith 

Lecture, April 12, 1900. 

44. Kruse. Deutsche med. Wochenschr., 1901, p. 370. 

45. Spronck. Cited by Park and Dunham; see ref. 66. 

46. Vedder and Duval. Jour, of Exper. Med., vol. vi, Feb., 1902. 

47. Lambl. Ber. aus dem Franz Josef-Kinderspital in Prag, Th. 1, 1860, p. 

362, etc. 

48. Lewis. Sixth Annual Rep., Sanit. Commission of India. Calcutta, 1870. 

49. Cunningham. Ibid. Seventh Annual Rep., 1870; Quarterly Jour, of 

Micros., 1881, p. 234. 

50. Grassi. Atti della soc. Italiani di scienze naturali, vol. xxiv, Milano, 1882 ; 

Atti della Real. Acad, dei Lincei Rendiconti, vol. iv, 1888, p. 83, etc. 

51. Gasser. Arch, de med. experim., No. 2, 1895, p. 198. 

52. Schuberg. Centralbl. f. Bact. u. Pathol., Bd. xiii, 1898, Nos. 18-22. 

53. Schardinger. Centralbl. f. Bact. u. Path., Bd. xiii, 1883, Nos. 18-22; 

Ibid, Bd. xxii, Nos. 1 and 3, Appendix. 

54. Quincke and Roos. Berl. klin. Wochenschr., 1893, No. 45, p. 1089. 

55. Hemmeter. Diseases of the Intestines, vol. i, Phila., 1901. 

56. Kelsch and Kiener. Arch, de Physiol., 1884. 

57. Vandenbossche. Gaz. Hebdom. de Med. et de Chir., Oct. 9, 1902. 

58. Josue. Bullet, de la Soc. de Biologie, March 13, 1897. 

59. Beaussenat. These de Paris, April, 1897. 

60. Pel. Cited by v. Leube; see ref. 61. 

61. v. Leube. Diagnose d. inneren Krankheiten, 1895, vol. 1, p. 186, etc. 

62. Mitchell. New York Med. Jour., Feb., 1866. 

63. Niemeyer. Lehrb. der spec. Pathol, u. Therapie. 

64. Quincke. Berl. klin. Wochenschr., 1899, No. 20. 

65. Park and Carey. Jour, of Med. Research, vol. ix, No. 2. 

66. Park and Dunham. N. Y. Univ. Bull, of Med. Science, vol. ii, Oct., 1902. 

67. Ewald. v. Leyden's Handb. der Erahrungstherapie, lte AurL, Bd. ii, 

S. 364. 

68. Osier. Practice of Medicine, 3d edition. New York, 1903. 

69. Weir. New York Med. Rec, Aug. 9th, 1903. 



CHAPTEK XY 

HABITUAL CONSTIPATION. DISPLACEMENTS OF THE 
INTESTINES* 

A. HABITUAL CONSTIPATION 

Preliminary Remarks. — By habitual constipation we understand 
a condition in which the intestine irregularly or incompletely 
evacuates its contents. An estimate of the normal frequency of 
defecation is intentionally omitted from this definition, for this may 
be greater or less without giving rise to a morbid condition. Every 
physician of experience knows, and every text-book of special pa- 
thology mentions, examples of extraordinary infrequency of defeca- 
tion without disturbance of health. Less known and appreciated, 
and doubtless not so common, is the physiological occurrence of 
the opposite condition — that is, an unusual frequency of defecation, 
the stools being otherwise normal. Of this I have observed several 
examples. 

There is a sharp line to be drawn between this condition and 
morbidly retarded defecation with its train of consequences. The 
latter is sometimes an acute and sometimes a chronic condition ; it 
may be artificial, or it may result from alimentary causes ; occasion- 
ally it accompanies or is the sequel of other not wholly intestinal 
disorders ; finally, it may be idiopathic, or, to speak more accurately, 
be independent of any recognisable organic cause. 

Of the forms just mentioned, alimentary constipation, on account 
of its great practical importance, deserves a few remarks. It owes 
its origin, no doubt, to a perverted or insufficient diet. It is specially 
observed among the higher classes where there exists a very obstinate 
traditional preference for what is called a " nourishing diet " (meat 
and fish), or, in general, for very easily digested food. Deficient 

* Illoway : Constipation in Adults and Children, New York, 1897, is a very 
useful and complete monograph on constipation, which we can recommend to the 
reader who is interested in details. 
272 



HABITUAL CONSTIPATION 273 

bodily exercise and work is often an associated cause. Further fac- 
tors consist in irregularity of life in every sense — in time of meals, 
of sleep, of work, and, of course, in the act of defecation itself. 

As a secondary condition, habitual constipation is found in con- 
nection with a great variety of diseases belonging to every depart- 
ment of medicine and surgery, and no attempt will be made to 
enumerate them. Constipation, as a complication or sequel of other 
intestinal affections, will be treated of under the headings of these 
affections. 

As to the other form of habitual constipation, that to which, in a 
strict sense, Nothnagel 1 applies this term, it is difficult to decide 
whether it is due, as he supposes, to a functional abnormality of the 
intestinal nervous apparatus ; or, as Emminghaus 2 has recently an- 
nounced on the basis of careful histological research, to changes in 
the splanchnics ; or how far the condition is, according to Dunin 3 , 
one of the features of anomalies of the central nervous system 
(neurasthenia, hysteria) ; or, finally, as G-lenarcl 4 has endeavoured 
to show, whether it is dependent upon displacements of the intes- 
tines (enteroptosis). 

It must be admitted that each of these hypotheses has a basis in 
clinical experience, but no single one will serve to explain the mani- 
fold varieties met with in daily practice. As Dunin has elucidated 
in his excellent paper, there is evidently in many cases a vicious 
circle, which when well developed may obscure the initial cause of 
the malady. For illustration, let us suppose a case such as we see 
almost every day. A woman who has previously been healthy be- 
gins to suffer from constipation and uses laxatives ; gradually these 
lose their effect, and defecation becomes more and more difficult 
and less complete. Hand in hand with this goes a failure of nutri- 
tion, either as a result of the abuse of laxatives or from therapeutic 
measures (an " easily digested diet "), or as a result of the general 
failure of health or of ansemia or gastric disorders (atony, for ex- 
ample). The natural result is emaciation, prolapse of the viscera, 
and with it increase of the constipation, and finally, as the climax 
of all these symptoms, the clinical picture of well-marked neuras- 
thenia. 

Every one of experience will recognise that in this case the en- 
teroptosis is not the cause but the result of the habitual constipa- 
tion, and the same is true of the neurasthenia. On the other hand, 
emaciation from any cause may lead to prolapse of the viscera and 
thus cause constipation, or, more accurately speaking, favour it; and 



274 DISEASES OP THE INTESTINES 

in this manner, as Dunin had in mind, pure neurasthenia may lay 
the foundation for the most obstinate kind of constipation. 

Symptomatology and Diagnosis 

Habitual constipation occurs in several grades of severity and 
in several clinical forms, the differentiation between which is of 
practical importance. 

We may distinguish the mild, medium, and severe types. But 
what do we understand by this ? That a certain accord exists 
between the duration and intensity of the disease is undeniable, and 
this would be a good diagnostic test if experience did not show that 
there are many exceptions. In patients who have become con- 
stipated from any cause, the condition may in a very short time 
run an obstinate course, and be very rebellious to treatment. Nev- 
ertheless, the duration of the disease, as well as the existence of 
an unmistakable hereditary or, perhaps more accurately, a family 
tendency which has shown itself in the development of the con- 
dition in early childhood, has a significance not to be underesti- 
mated. 

As previously mentioned, I have found that we can judge of 
the intensity of the process by the results obtained from the use 
of purgatives. When the most severe drastics, used in large doses 
for years, fail to produce their effect, it is safe to assume that the 
case is a severe one, and, from a therapeutic standpoint, not a very 
promising one. 

In badly neglected cases, especially in women, the faecal accu- 
mulations may form tumours. These are sometimes situated in 
the large intestine, usually in the caecum or the neighbourhood 
of the sigmoid flexure, and may cause the outline of the intestine 
to stand out in relief ; or they may be located in the rectal pouch 
and attain such a size as to dilate the latter like an aneurismal 
sac, It is well known that faecal tumours may exist and yet the 
defecation be apparently normal or even diarrhoeal in character, a 
byway having been formed through which the dejections pass. 
Under certain unfavourable circumstances symptoms of obstruction 
which may require surgical intervention, may develop. These cases 
will be discussed in the chapter on Intestinal Stenosis. 

Very convenient for clinical purposes is Fleiner's 5 division into 
two classes, the atonic and the spastic forms. My own experience 
would lead me to add a third, which might be called the fragmen- 
tary. 



HABITUAL CONSTIPATION 275 

The atonic variety is the usual form of constipation that depends 
upon simple weakness of the intestine, such as usually develops 
under improper habits of living and eating. According to Fleiner, 
the stools are drier and firmer than usual, and consist of compressed 
and desiccated lumps or cylinders of large calibre, or of distinct 
particles or scybalae bearing the impress of the sacculations of the 
colon. 

The spastic form is due, according to Fleiner, to the retention 
of firm masses of faeces within segments of spastically contracted 
intestine, somewhat as in lead colic. It is found chiefly in neuras- 
thenics, hypochondriacs, and in women with pelvic disorders. The 
stools have the following characteristics : long or short cylinders 
of small calibre, often no thicker than a pencil or the little finger, 
or spherical masses of faeces of the size of a hazel nut. The latter 
formation is not characteristic of spastic constipation, as it is also 
found in the atonic form ; it is only when constantly present that 
it is significant. 

I can confirm Fleiner's observation that there are numerous 
transition forms and combinations, and that both varieties may be 
associated with catarrh of the large intestine. 

As I have said, my experience leads me to distinguish a third 
form, fragmentary evacuation, on account of the peculiar subjec- 
tive and objective symptoms. 

These patients have regular spontaneous movements of the 
bowels, but the evacuations are incomplete, and therefore the call 
to defecation is frequently repeated. They are obliged to go to 
stool every two to three hours, and each time, with great straining, 
pass small quantities of cylindrical, or pointed, spherical, or pulpy 
faeces. The patients may have a sense of pressure and tenesmus 
in the rectum, or complain of a feeling of fulness in the abdomen, 
so that they make renewed attempts to empty the bowels, which 
may result in the evacuation of more of such fragments, or be quite 
fruitless. This variety seems to be especially frequent in men, and 
depends, I believe, upon a sluggishness of the lower segments of 
the large intestine, or sometimes of the rectum alone. On palpa- 
tion the latter may be found full of faeces shortly after one of these 
evacuations. 

Although this form may merge into the others or be combined 
with them, yet I think it is entitled to separate recognition on 
account of its significant symptoms. 

The following case is a good example of fragmentary stools : 



276 DISEASES OF THE INTESTINES 

Paul P., merchant, of Berlin, thirty-nine years old. Has been somewhat 
nervous ever since academic and university study. He suffers frequently from 
neuralgias, nervousness, and precordial distress. When he takes physical and 
mental rest there is temporary improvement. At the present time he complains 
chiefly of intestinal symptoms. He has six to eight movements of the bowels 
daily. Each time the evacuations are small, and of either firm or pulpy con- 
sistence. Defecation is preceded by an uncontrollable tenesmus. No mucus 
or blood in the stools. The evacuations which occur during the night are espe- 
cially troublesome. There is a marked sense of hunger after each passage. 
Examination of the intestines, particularly of the rectum and of the stools, 
shows nothing abnormal. 

A prominent symptom of habitual constipation, particularly of 
the spastic form, is intestinal colic. Attacks of most violent abdom- 
inal pain occur with or without noticeable meteorism. They some- 
times involve the entire abdomen, and sometimes only limited areas, 
occasionally lasting for hours, and subsiding suddenly after the ex- 
pulsion of much gas or an evacuation of faeces. These colics are 
present not only in constipation, but also, though less frequently, 
when the bowels move regularly. Perhaps in the latter case the 
evacuations are incomplete. Nothnagel* has also called attention 
to this fact. 

In habitual constipation Kobler 6 finds that albuminuria or cyl- 
indruria are not infrequently found ; with the cessation of the intes- 
tinal symptoms they vanish. 

The question already briefly discussed, as to the relationship 
between habitual constipation and certain cerebral manifestations — 
such as headache, sense of pressure in the head, psychic depression, 
which we designate at the present day by the comprehensive term 
neurasthenia — can be disposed of in a few words. 

An unprejudiced consideration leads us to divide the patients 
into three groups : (1) Severe intestinal hypochondriacs, whose every 
thought and aspiration is centered upon the function of defecation ; 
(2) neurasthenics, in whom the constipation is but one of many 
complaints ; and (3) individuals who either have no nervous dis- 
orders, or complain of nothing more than a sense of pressure in 
the head, or pain, or mild general malaise. In my experience, the 
last-mentioned category includes the great majority of cases. This 
alone would show that clinical observation does not give support 
to the trend of the doctrine of auto-intoxication which was ad- 
vanced by Yotsch 7 in the 70' s, and during the last decade by 

* Loc. cit., p. 34. 



HABITUAL CONSTIPATION 277 

Bouchard 8 , Feyat 9 , Glenard 4 , and others. I may say that 1 have 
been able to permanently cure the constipation in a large number of 
neurasthenics and constipation-hypochondriacs, but the symptoms 
of neurasthenia do not vanish, and the attention is merely diverted 
to some other disturbance. 

The diagnosis of habitual constipation seems at first sight to be 
an easy one. This is a great error. I feel bound to state that in 
the early years of my practice I used to make a number of mistakes 
in this direction. First of all, the rule must be laid down that when 
simple constipation is complained of a thorough general and local 
examination should never be omitted. Under the latter head rectal 
examination is certainly included, especially with reference to the 
presence of hemorrhoids, tumours, fissures of the anus or of the 
neighbouring integument, which, together with anomalies of the 
genital tract, hypertrophy of the prostate, tumours of the uterus 
or of the ovaries, retroflexions, etc., are often important etiological 
factors. In the General Section we have already spoken (page 76) 
of the frequent blunders made when faecal tumours are present, and 
we have pointed out how these errors may be avoided. But aside 
from such mistakes, which can almost always be avoided by careful 
examination, there are severe affections of the intestines which may 
be concealed under the guise of simple habitual constipation. These 
are, first, stenoses of the intestine of benign character; secondly, 
stenosing intestinal carcinomata. These cases, obscure in their early 
stages, but later often revealed in a sudden and very disagreeable 
manner, will be described under their appropriate headings. The 
following remarks are limited to a few points of practical impor- 
tance. 

Individuals of or beyond middle age, who have previously been 
healthy and never have had any intestinal trouble, and who without 
appreciable cause begin to suffer from habitual constipation, should 
a priori be suspected of having intestinal stenosis (usually malig- 
nant). This suspicion is strengthened if there is progressive ema- 
ciation. The occasional occurrence of attacks of colic should attract 
immediate attention. In such cases, even in the absence of a tumour 
that can be felt, the chain of evidence is very nearly complete, and 
it only remains to recognise the objective signs of stenosis by care- 
ful clinical observation. 

]SText to these most frequent and dangerous mistakes, a perma- 
nent and severe grade of obstruction may be caused by adhesions 
between coils of the intestine, incomplete volvulus, chronic invagina- 

19 



278 DISEASES OF THE INTESTINES 

tion, etc. It will suffice to mention them here, as they will be dis- 
cussed in the chapter on Intestinal Stenosis. 

It is undoubtedly of importance to distinguish between a con- 
stipation arising from insufficiency of the muscular coat of the 
intestine and that of catarrhal origin. These can usually be differ- 
entiated from each other by inflation and methodical filling of the 
intestine with water in one case, and by intestinal irrigation in the 
other. The methods by which these may be accomplished do not 
differ essentially from those described in the General Section and 
in the chapter on Enteritis. 

Treatment 

The therapeutic problem in habitual constipation is that of 
inducing regular and adequate evacuations of the bowels. It should 
not be considered solved until the bowels move regularly without 
the assistance of mechanical or medicinal co-operation, the diet 
being normal or nearly so. The ways in which this may be accom- 
plished are numerous, and it seems to me that the energy and con- 
sistency with which any one of these is carried out counts for more in 
obtaining a good result than the particular method itself. 

Sometimes, when one method or another fails, several methods 
may very often be combined, and we do not doubt that in this way 
also something may be accomplished. In everyday practice such a 
procedure may indeed be justifiable, for the physician takes what is of 
advantage from any source ; but from a scientific standpoint I must 
utter a protest against superfluous confusion of therapeutic methods. 

In the introductory chapter of his G-uide to Clinical Thera- 
peutics, Penzoldt 10 has very justly remarked that a combination of 
methods makes the estimation of the value of any one of them 
extremely difficult. When a good result has been obtained, it is not 
clear which has been the active or most active agent, and too much 
credit or discredit may be attributed to one or the other. Unsuc- 
cessful results may be due to neglect or omission of the essential 
feature while the patient is occupied with what is of no importance. 
Besides all this, a multiplicity of methods or therapeutic procedures, 
such as are observed in certain lay hygienic establishments as well as 
in some managed by physicians, is by no means necessary for the 
patient; he returns from them loaded with a confusion of false 
ideas, which are difficult to eradicate by the authoritative opinion of 
medical men. I think it proper to allude to this subject — which is 
equally pertinent in other disorders than chronic constipation — as a 



HABITUAL CONSTIPATION 279 

warning against the danger of the various physical or mechanical 
fads which have begun to mark the reaction against the abuse of 
prescription writing. 

The methods for the treatment of chronic constipation which 
will be considered are the prophylactic, the dietetic, the mechan- 
ical, the electrical, the thermic, and the medicinal. 

1. The prophylactic treatment of constipation, which I know 
to be too little appreciated, should begin in childhood, and consist 
in appropriate rules for the child. It is the mission and the duty 
of parents to supervise the intestinal activity of children, to teach 
them to have evacuations at a set time, and, when necessary, to 
modify the diet under medical advice until such movements are 
satisfactory. The habitual use of laxatives during the first few 
years must, as has already been said (page 190), be prohibited. 
Such measures are especially necessary in families which have an 
inherited tendency toward atony of the intestine. It is hard to 
exaggerate the importance of prophylaxis during pregnancy, a 
condition which experience teaches us is often, chiefly on account 
of the local conditions, associated with more or less constipation. 
In these cases it is to be combatted by appropriate food (see below), 
and, as von Wild n has urged in his excellent essay, by gymnastic 
exercises, so as to endeavour to increase the strength of the abdom- 
inal muscles. The same is true of pareses due to long rest in bed 
during infectious diseases or after operations, etc. 

2. The Diet. — We have discussed the essential principles of a 
rational diet in chronic constipation in the General Section (see page 
146 et seq.). These will suffice for the preparation of suitable special 
dietaries. Detailed and very appropriate diet schemes have been 
given by Penzoldt 12 , Rosenheim 13 , and Wegele 14 . We prefer that of 
Penzoldt, because it is very simple and practical : 

7 a. m. — A glass of cold water. 

8 a. m. — A liberal breakfast, with sweetened coffee, a good deal 

of butter, honey, and Graham bread or pumpernickel, 

after which the patient should go to stool. 
1 p. m. — Midday meal of meat, a good deal of vegetables, salad, 

stewed fruits, farinaceous food, half a bottle of light 

wine (Moselle, or cider). 
7 p. m. — Meat, with a good deal of butter ; Graham bread, stewed 

fruit, and beer. 
10 p. m. — Before retiring, fresh or stewed fruit. 



280 DISEASES OF THE INTESTINES 

The dietaries of Bosenheim and Wegele differ from the above 
in that they add, once or twice a day. 300 grams of buttermilk or 
kefir, which in severe cases increases the effect of the diet. 

In the great majority of cases a permanently good result is 
obtained by the use of this method — that is, without systematic adher- 
ence to the above regime the bowels will move under the usual diet, 
provided it is rich in carbohydrates. Even in older, indeed in very 
chronic cases, contrary to my prognostication, I have seen very ex- 
cellent results from the use of this simple constipation diet. Some 
cases soon have a relapse, partly because the patient is not persistent 
enough, and partly because — as in the case of medicinal agents — 
dietetic laxatives may lose their effect after a time. In the latter 
cases, which in my experience are certainly unusual, supplementary 
measures must be employed. 

It may not be superfluous to remark that the diet above described 
is only suitable for uncomplicated cases of chronic constipation. 
When complications exist it can not be used, or must be materially 
modified. For example, this diet is obviously contra-indicated in 
diabetes mellitus, in obesity, or in a tendency thereto, and in well- 
developed alimentary glycosuria. The discomforts which it occa- 
sions (pyrosis, oppression, vomiting, pain, hemorrhages, etc.) in 
gastric atony, hyperacidity, ulcer of the stomach, gastric dilatation, 
carcinoma of the stomach, carcinoma of the intestine, etc., naturally 
will forbid its use in these conditions. Undue flatulence may con- 
tra-indicate such a large quantity of sweets and acids. A careful 
choice of the foods which are well tolerated, as shown by prudent 
variations and experiments, will accomplish the desired results. It 
would lead us too far to go into particulars with reference to all the 
considerations in question. 

Everyday experience shows that the milder cases will get along 
with much less change in diet. For example, it will suffice in very 
many cases to give Penzoldt's advice as to the glass of cold water in 
the morning, especially if a little common salt is added ; in other 
cases the taking of fresh or cooked fruit on an empty stomach or 
in the evening is sufficient ; or the morning cigar may set up intes- 
tinal peristalsis. Nor do these exhaust the possibilities. We can 
occasionally utilize these facts in treatment, at the same time that 
they throw light upon the wide individual variations in the irrita- 
bility of the intestines in different subjects, and on the necessity of 
taking this factor into account in each individual case. 

3. Mechanical Treatment. — The most important of such meas- 



HABITUAL CONSTIPATION 281 

ures is massage ; it has already been discussed in the General Sec- 
tion (pages 170-172). To this may be added, in many cases, other 
mechanical therapeutic agents. 

The simplest of these are exercise, and various systems of gym- 
nastics. 

The value of the former should not be underestimated, although 
experience teaches us not to expect too much from it. We often 
enough meet with chronic constipation in people such as farmers 
and officers who take active exercise. The fact that surprisingly 
good results are obtained in the treatment of constipation in spite 
of absolute rest in bed, shows that the importance of exercise has 
heretofore been very much overestimated. For these reasons I 
have been led to prescribe rest in bed, with suitable diet, in some 
cases of severe constipation ; and I particularly remember the case 
of a lady who was suffering from a severe type of constipation — 
whose medical adviser, in his perplexity, finally felt compelled to 
order her to take a bottle of bitter water every hour — who was com- 
pletely and permanently cured by four weeks of absolute rest in bed, 
with no other treatment than an appropriate diet. 

Much more valuable than simple exercise are the various forms 
of indoor gymnastics, calisthenics, rowing, bicycling, riding, tennis, 
bowling, football, and the Swedish movements, when they are 
carried out more or less methodically. But they are not all equally 
useful. For example, my experience shows that bicycling does 
not exercise any especial influence over intestinal activity ; indeed, 
one of my most obstinate cases was in the person of one who was 
moderately addicted to this sport. The same is also true of riding. 
Rowing seems to be more useful, but, unfortunately, it is not always 
available. For the same purpose, the so-called rowing machines 
have been extensively recommended by some writers. 

The importance of calisthenics and systematic indoor gymnas- 
tics, as explained in numerous books on this subject (Schreber, 
Fromm, and others), should not be underestimated. One of the 
most useful movements for strengthening weak abdominal muscles 
consists in raising the trunk slowly from a horizontal to an upright 
position without the assistance of the arms or legs, and then allow- 
ing it to slowly drop back again ; this should be repeated several 
times each day. It is best practised in a progressive fashion, very 
gradually increasing the angle at which the trunk is maintained by 
the muscular exertion. Ultimately the motion of rising may be made 
against a slight resistance, such as that of the hand of an assistant 



9S2 DISEASES OF THE INTESTINES 

laid upon the forehead (von Wild). Another useful exercise is 
high kicking of the knee, so that the anterior surface of the thigh 
is brought into forcible contact with the abdomen. 

As TVillianis 15 , Lauder Brunt on 16 , and recently Ewald 17 , have 
pointed out, the position of the body during the act of defecation, 
belongs in a certain degree to this class of measures. These 
authors emphasize the advantage of a squatting position, in which, 
as is evident, the abdominal muscles act upon the rectum to best 
advantage. Anyone who knows from experience how difficult it is 
to have an evacuation in a sitting posture with the legs extended 
(bedpan position), will concur in the advice of these authors, but, 
unfortunately, there are practical difficulties in the way of carrying 
it out. 

-1. Concerning the use of electricity, its indications and advan- 
tages, see the discussion on pages 1T2-1 To. 

5. With the thermic measures may be classed the various forms 
of hydrotherapy, which have been described on page 158. Their 
effect depends chiefly upon an improvement in the general condition, 
by which, as we have seen, nutrition and intestinal activity are 
increased. Local or intestinal hydrotherapy is also of importance 
in the form of douches and enemata (page ITT), the latter contain- 
ing substances which soften faeces (oil, soap, glycerin, etc.). It is 
also known that the sudden local application of cold will increase 
intestinal peristalsis, and this fact may be taken advantage of in 
therapeutics. The most simple and at the same time a very effi- 
cient method, according to my experience, consists in the use of cold 
water compresses (of course without an impervious covering). A 
more powerful application is the use of cold, or alternate cold and 
hot jets or sprays over the abdomen (Scottish douche). The ether 
spray is another and very simple method, which I have used in 
obstinate cases for a number of years. Once or twice a day, for 
about live minutes, 100 cubic centimetres of sulphuric ether are 
sprayed upon the abdomen with the Richardson apparatus. The 
chilling so produced markedly stimulates the muscles of the abdom- 
inal wall, and presumably also the intestine, for it soon gives rise to 
an urgent desire to go to stool. I will merely select two of my case 
histories in which the ether spray gave brilliant results: 

Case I. Obstinate const ijx/.t ion, not cured by diet alone. Complete cure by 
ether spray. 

B., resident of Berlin, fifty -four years old, has suffered for many years from 
severe pyrosis and constipation. V\~ a5 operated on for hernia in 1896, but with 



HABITUAL CONSTIPATION 283 

little improvement in the constipation. Movements from the bowels occur 
only after laxatives or enemata. The urine contains a good deal of uric acid, 
but there are no other signs of gout. Examination of the gastric contents 
shows a high degree of hyperacidity with atony. Rectum empty. Irrigation 
does not show the presence of mucus. Constipation diet was first tried. A 
passage resulted each day, but only with great difficulty, and the amount was 
insufficient. In May, 1897, the ether douche was used twice daily for about 
five minutes. The evacuations were from this time on softer and more free. 
After a fortnight's use of the spray the stools were normal. Subsequently the 
patient used it from time to time when there was delayed evacuation. Since 
the year 1898 the bowels have been perfectly regular on simple constipation 
diet. He has gained 6 kilos in weight since the beginning of the treatment. 
The hyperacidity has been improved by the continuous use of citrate of soda. 

Case II. Chronic constipation of three and a half years' standing. Great 
abuse of drastics. Results from diet unsatisfactory. Regular action of the bowels 
results immediately from the use of the ether spray. 

Miss L., of Frankfurt-am-Main, twenty-three years old. The patient has 
suffered for the past three and a half years from severe atonic constipation, 
with resultant anaemia and anorexia. Purgatives of the drastic order, which 
the patient has used for a long time, always cause severe pain. At one 
period membranous enteritis developed, but disappeared later. At first the 
treatment in my private clinic consisted in constipation diet, but the bowels 
would not move spontaneously. Evacuations only followed the use of enemata 
of soapsuds, glycerin, or oil. Fourteen days after admission the use of the 
ether spray was begun, for five minutes once daily. The bowels moved daily 
thereafter, and after ten days of this treatment the spray was left off. The 
patient gained 15 pounds in weight, and left after four weeks, the bowels being 
perfectly regular. 

Such favourable results are not obtained in all cases, but, be- 
cause of its simplicity in obstinate cases, the ether spray should be 
considered almost as important as the diet. 

6. 2fedicinal Treatment. — In recent times there is a good deal 
of diversity of opinion among authors as to the benefit or the harm 
that may result from medicinal treatment — that is, from the use of 
laxatives. Even if we ignore the exaggerations of " the doctor who 
follows Xature," and whose stock in trade it is to denounce all drugs 
as poisonous and harmful, there still remains between leading clini- 
cians and physicians a gulf difficult to bridge over. 

As representing one set of opinions I may quote Dunin 3 , who 
" most positively forbids the use of any sort of laxative whatever," 
and of the other, the elder clinician v. Liebermeister 18 , who gives 
the advice that when regular stools can not be obtained without too 
much trouble by dietetic regulation, " suitable laxatives are to be 
used with regularity each day." Of the standard authors, Pen- 



284 DISEASES OP THE INTESTINES 

zoldt 10 , Nothnagel \ Fleischer 19 , Kosenheim 13 , Ewald w , and others 
take a middle position. We can especially recommend Penzoldt's 
thorough and clear presentation of the facts of the controversy. 

In what follows I shall give the results of my own experience in 
this matter. I must concur in the opinion of other investigators 
who deny that laxatives always, or in a majority of cases, have a 
harmful action. I know numerous healthy people who have taken 
a daily laxative for ten years — particularly rhubarb — without any 
injury to the intestine or to their general health. These people 
would with justice indignantly refuse to exchange their efficient and 
simple pill for monotonous and burdensome dietetic regulations. 
From this sort of case — one which seldom comes under professional 
notice — are to be distinguished two other varieties : the first, in 
which laxatives do have an effect, but occasion gastric * or intestinal 
discomfort, loss of appetite, emaciation, etc., and second, those in 
which laxatives have either no action or only an inadequate one. 
In both cases it is not a question of the further use of laxatives, for 
by the time that the patients seek professional advice the milder 
agents have ceased to act, and they have found that the more pow- 
erful ones sooner or later become inert against the intestinal tor- 
pidity, or augment the other discomforts just mentioned. 

It is in these very cases that a rational diet, possibly in con- 
junction with some of the above-described methods, achieves its- 
greatest triumph ; and, even when it is not fully successful — as some- 
times happens in very protracted cases — a satisfactory result may 
be obtained with the assistance of small, perhaps minimal doses of 
some mild laxative, or, still better, by enemata of some suitable fluid 
(oil, etc.). 

Thus the question as to the indications for the use of laxative 
drugs is virtually self- answered. [Aside from the above-mentioned 
cases in which their long- continued use has produced no injurious 
effects], we employ this class of drugs only when a constipation diet, 
patiently persevered in, and if necessary assisted by other methods, 
is found inefficient. 

We have already expressed our views concerning the choice of 
laxatives in the General Section (page 186 et seq.), and have pointed 
out that each of them has its special use and indications. These 
are essentially dependent upon the state of the stomach and, in cer- 

* Wiczkowski has recently made the interesting observation (Archiv f. Ver- 
dauungskrankheiten, Bd. iv, S. 407) that laxatives materially diminish, while- 
opiates increase, the acid secretion of the stomach. 



HABITUAL CONSTIPATION 285 

tain cases, of the liver. For instance, calcined magnesia and 
Carlsbad salts are also very excellent antacid remedies, and podo- 
phyllin and euonymin equally good cholagogues. In appropriate 
cases advantage must be taken of such facts. 

Laxatives may often be administered by the rectum in the form 
of small enemata or as suppositories. The most popular and effi- 
cient, especially in the milder cases, is glycerin in doses of 1 to 8 
grams. It is evident that their effect does not extend beyond the 
lowermost segments of the colon. Hiller 20 and, more recently, 
Kohlstock 21 have recommended the use of the active principles 
of approved laxatives per rectum. According to Kohlstock, the 
most serviceable are aloin, cathartic acid, and, for especially obstinate 
cases, colocynthin and citrullin. The following are the formulae : 

5 Aloin 1.0 

Formamid 10.0 

(A suitable dose is 0.1 to 0.5 of aloin.) 

I£ Colocynthin 1.0 

Spirit., 

Glycerin aa 12.0 

(A suitable dose of colocynthin is 0.01 to 0.01.) 

^ Acid, cathartinic. e senna 3.0 

Aq. destillat T.O 

Sod. bicarb, q. s. ad react, alkalin. 
(A suitable dose of cathartic acid is 0.6.) 

^ Citrullini 2.0 

Spirit., 

G-lyceringe aa 19.0 

(A suitable dose of citrullin is 0.02.) 

Kohlstock states that these concentrated enemata are prompt 
and painless in their action. The only obstacle to their more gen- 
eral use is their high cost.* 

Up to the present time the subcutaneous use of purgatives 
(aloin, colocynthin, citrullin, etc.) has not been very successful. 
Reference should be made at this point to the subcutaneous use of 
magnesium sulphate in doses of 0.12 to 0.18, as recommended by 
Wood 22 and by Eakins 23 . Wood states that he has obtained results 
in 70 per cent of cases of constipation ; and Eakins, that even in a 
case of faecal obstruction he obtained copious evacuations and cessa- 

* The preparations mentioned are manufactured by Merck (Darmstadt). 



286 DISEASES OF THE INTESTINES 

tion of the threatening symptoms after ten hours. Scarbinato M also 
had positive results, although, as he mentions, the effect of subcuta- 
neous treatment is neither marked nor constant. 

My own investigations with doses as large as 0.5 of magnesium 
sulphate were not productive of any distinctly noticeable laxative 
effect. 

In the same communication Scarbinato describes another pro- 
cedure Avhich is scarcely known, at least in Germany : the endermic 
treatment of constipation by croton oil (6 to 10 drops in 15 to 20 
gm. ol. olivae). In four patients with chronic constipation, this 
procedure produced regular fluid movements, often accompanied 
by abdominal pain. Oleum ricini, used in the same way, gave 
negative results. 

Those substances which set up peristalsis by mechanical irrita- 
tion occupy a mid-position between medicinal and dietetic agents. 
Among these are the preparations of linseed, of which a table- 
spoonful is allowed to soak in water and taken as a drink on an 
empty stomach. A particularly agreeable and, as I know, an effi- 
cient variety is the linseed of Tarin, which is distinguished by its 
large size and elegant shape. The large amount of oil contained 
in these preparations seems to account for part of the effect. It 
appears to me very possible for some of the seed husks to gain access 
to the vermiform appendix and thus give rise to inflammation. This 
may be a purely theoretical idea, but it has nevertheless deterred 
me from a very extensive use of this simple and efficient remedy. 

7. The hydr other apeutic treatment of chronic constipation has 
been discussed in the General Section (page 158). 

Among the complications of chronic constipation, the treatment 
of flatulent colic deserves brief mention. 

As we are here dealing with a spastic condition of the intestinal 
canal, the preference should be given to opium in small doses (ext. 
opii, 0.01 to 0.02). Such doses will not only allay the pain but will 
promote an evacuation. The use of laxatives, or, better still, of a 
suitable enema, is indicated only after the painful contractions have 
subsided. 



DISPLACEMENTS OF THE INTESTINES 287 

B. DISPLACEMENTS OF THE INTESTINES 

Symptomatology and Diagnosis 

A short review of the most important anomalies of position of 
the intestines has been given in the General Section (page 20 
et seq.), and to this we refer the reader. In what follows, an 
attempt will be made to discuss briefly the clinical manifestations 
and the resultant therapeutic indications. For practical purposes, 
dislocations of the large intestine need be alone considered. Those 
of the small intestine produce appreciable symptoms only when 
there is a marked interference with peristalsis, such as may arise 
from acute kinkings, as caused by tumours, adhesions, compressions, 
etc. We shall return to this subject in the chapter on Stenoses of 
the Intestine. Malpositions of the large intestine may either exist 
for a long time without causing any disturbance of well-being, or 
may occasion manifold symptoms, or, finally, may disguise the clin- 
ical picture to such a degree that only a lucky chance, or an autopsy 
in vivo, or sometimes only a post-mortem examination, will show 
the true condition of affairs. 

The functional disturbances which, as has been said, are some- 
times present were not unknown to the older physicians — Mor- 
gagni, De Haen, Esquirol, and Ruysch. Yirchow 25 , in his famous 
treatise on the Diseases of the Abdomen, from an Historical, Crit- 
ical, and Scientific Standpoint, has long ago and in a classical man- 
ner described the importance of peritoneal fixation as affecting the 
onward progress of faeces. The pathological importance of dis- 
placements was at times quite forgotten or underestimated, and 
at times unduly exaggerated (Esquirol, Yotsch), until recently the 
subject has been given a new prominence by Landau's fruitful 
researches on the subject of floating kidney and pendulous abdomen, 
and Glenard's original though somewhat fantastic doctrine of en- 
teroptosis. The valuable contributions of Leichtenstern 26 , Cursch- 
mann 27 , and Fleiner ^ have notably enriched our knowledge con- 
cerning the origin and clinical significance of displacements of the 
intestines. 

According to Fleiner, displacements of the colon may owe their 
origin to abnormal curves and angular flexures which interfere with 
the fsecal movements. These are favored by increased pressure 
upon certain segments of the large intestine by ill-fitting corsets, 
belts, or, in the case of men, by an habitual stooping carriage and 



288 DISEASES OF THE INTESTINES 

sedentary mode of life. In this way dilatation of the affected seg- 
ments occurs, faeces and gas accumulate, and the clinical picture of 
atonic constipation is developed. 

Soon organic changes in the wall of the intestine occur. Catarrh 
develops, and there is then added diarrhoea, or diarrhoea alternat- 
ing with constipation, or constipation with membranous enteritis. 
Neuralgic colicky pains set in, which, according to Fleiner, are 
easily mistaken for intercostal neuralgia, biliary colic, renal colic, 
spinal crises — even for duodenal ulcer. Fleiner has given the 
details of several very instructive clinical histories which show how 
difficult it is to avoid mistakes, especially in confounding these 
paroxysmal pains with biliary colic. I can add from my personal 
experience that it frequently happens, especially in women, that the 
symptoms of gastrointestinal neurasthenia are present. There are 
anorexia, oppression in the epigastrium, intestinal colic, flatulence, 
constipation, mental depression, disinclination for work, loss of 
weight, etc. Objective signs are ptosis of the stomach and colon, 
displacement of the kidneys, liver, or spleen, and sometimes of the 
uterus. 

Many physicians are puzzled when they come to deal with this 
condition. Some think of anaemia and prescribe iron ; others sus- 
pect gastric or intestinal catarrh and prescribe bismuth or laxatives ; 
others diagnosticate hysteria and attempt to cure with valerian, 
bromids, or asafoetida. 

Displacements of the intestine may, however, cause very dan- 
gerous changes in the intestines, and may endanger life. Thus 
Curschmann has described two cases of upward flexure of the 
caecum with absolute occlusion of the intestine from the acute 
bending. Both patients died with symptoms of acute obstruction. 
When there are abnormal bends of the transverse colon and its 
flexures, there may be an acute angle formed which causes partial 
or total obstruction. 

These changes of position are of clinical importance also, be- 
cause they may lead to errors in diagnosis not liable to arise in any 
other way. Curschmann has reported very interesting cases in 
which the caecum was bent so as to bring the vermiform process 
directly into contact with the liver (see Fig. 24). If the appendix 
became inflamed in this situation the exudate would be close to the 
right costal arch. 

In case of congenital shortness or absence of the ascending por- 
tion of the colon, the caecum with its appendix might be close to or 



DISPLACEMENTS OF THE INTESTINES 



289 



behind the liver. In a case described bj Cnrschmann (see Fig. 25), 
a perforating perityphlitis was present while the clinical signs were 
those of cholelithiasis. 

Dislocations of the colon are especially liable to be confounded 
with diseases of the liver, von Leube 29 , and subsequently Fleiner 28 




Fig. 24.* — Vermiform Appendix in Con- 
tact with the Under Surface of 
the Liver. (Curschmann.) 



Fig. 25. — Vermiform Appendix lying be- 
hind the Eight Lobe of the Liver. 
(Curschmann.) 



and Curschmann 27 , have called attention to the fact that abnormal 
elevation and gaseous distention of the transverse colon may reduce 
or abolish the area of liver dulness. 

I have often observed the absence of liver dulness in males. 
As Curschmann observes, this may often cause difficulties in map- 
ping out the edge of the liver in hepatic cirrhosis. The normal 
position of the liver dulness in the anterior and posterior axillary 
lines enables a decision to be reached. In one of the cases which 
Curschmann has described and illustrated, a duodenal ulcer was 
mistaken for a subphrenic abscess because the flexures of the colon 
were absent, both limbs running almost parallel. According to 
Curschmann, when the flexures are exaggerated into loops the 
splenic dulness may be obscured. 

It is well known that loops with coincident elongation are found 



* Thanks are due to Professor Curschmann, of Leipzig, for permission to re- 
produce Figs. 24-28. 



290 



DISEASES OF THE INTESTINES 



with especial frequency in the transverse colon and at the flexures. 
They are chiefly single ; next in frequency come the M or V 
shapes, and rarely the double looping seen in Fig. 26. If the 
flexures become still further enlarged, they may dip down as far as 





Fig. 26. — Double Looping of the Trans- 

verse Colon. (Curschmann.) 



Fig. 27. — Double Looping of the Sig- 
moid Flexure. (Curschmann.) 



the brim of the pelvis. It has long been known that abnormal 
loops of the sigmoid flexure may give rise to serious mistakes. 
We have already mentioned (page 23) that when the sigmoid flexure 
is strongly inflated, it almost always encroaches upon the right lower 
quadrant of the abdomen, and therefore lies close to the caecum. 
When there is a suspicion of volvulus in that region, the physical 
signs of distention of the sigmoid flexure should be looked for. 
The importance of abnormal loops of the sigmoid flexure when 
operative procedures are in question, when an artificial anus is to be 
constructed, or when a loop is to be exsected, is of course evident. 
The difficulties may be very much increased when an abnormally 
long sigmoid flexure is arranged in a double (Fig. 27) or in multiple 
loops (Fig. 28). 

The latter condition may be considered on the border line be- 
tween normal and pathological ; it presents favourable conditions 
for the formation of a volvulus. 

The diagnosis of certain forms of intestinal dislocation, such as 



DISPLACEMENTS OF THE INTESTINES 



291 




Fig. 28. — Multiple Looping of the 
Sigmoid Flexure. (Curschmann.) 



the common depression or elevation of the transverse colon, offers 
no special difficulty. In most instances gross variations of this kind 
can be determined with probabili- 
ty or certainty by inflation of the 
intestines with air, by methodical 
distention with water, or by care- 
ful percussion. The case is quite 
different with displacements of the 
caecum, deformities and disloca- 
tions of the sigmoid flexure, ab- 
sence of the flexures, abnormal 
looping, and other irregular con- 
ditions. The possibility of an 
anomaly of position must be taken 
into consideration in making a di- 
agnosis. Curschmann was fortu- 
nate enough to do this in one in- 
stance. Perhaps the capsule meth- 
od, with the assistance of the Kont- 
gen rays, as recently described by 
Levy-Dorn and myself 30 , will have some value for the recognition 
of these anomalies of position or form. Practical experience is, 
however, still lacking. When the clinical signs are obscure, the 
possibility of such variations must be taken into consideration. 

Treatment 

The description of the treatment of changes in position or form 
of the bowel touches upon many chapters of intestinal pathology ; 
it is not possible, therefore, to enter into details in this place. 
Prolapse of the transverse colon, however, which is usually only a 
part of a general visceral ptosis, requires a few brief remarks. The 
fundamental therapeutic maxims agree essentially with those in gas- 
troptosis (see Diseases of the Stomach, Part II, page 183). They 
consist primarily in complete rest in a horizontal position and in a 
strengthening diet. The latter should not be a routine one, such 
as Weir-Mitchell's, but should be adapted to the necessities of each 
case, with reference to the functional disturbances of the alimentary 
canal. 

Constipation or colitis must be treated in the manner advised in 
the chapters on these affections. By the use of massage, hydro- 
therapy, and electrotherapy, the effects of the dietetic prescriptions 



292 DISEASES OF THE INTESTINES 

may be enhanced and the general condition improved. A suitable 
abdominal supporter is useful in assisting the weak abdominal 
muscles. 

Treatment in a sanitarium is far preferable to home or ambu- 
latory treatment. 

LITERATURE 

1. Nothnagel. Darmkrankheiten, S. 27. 

2. Emminghaus. Mtinchener med. Wochenschr., 1894, No. 5 u. 6. 

3. Dunin. Ueber habituelle Stuhlverstopfung, deren Ursachen u. Behand- 

lung, Berliner Klinik, 1891. 

4. Glenard. De l'Enteroptose, 1889. 

5. Fleiner. Berliner klin. Wochenschr., 1893, No. 3. 

6. G. Kobler. Wiener klin. Wochenschr., 1898, No. 20. 

7. Vootsch. Koprostase, 1874. 

8. Bouchard. Lecons sur les Autointoxications, Paris, 1887. 

9. Feyat. De la Constipation et des Phenomenes qu'elle provoque, 1890. 

10. Penzoldt, Klinische Arzneimittellehre, 3te Aufl , S. 20 u. f. 

11. von Wild. Sammlung zwangloser Abhandlungen a. d. Gebiete der Frau- 

enheilkunde u. Geburtshiilfe, 1897, Bd. ii, Heft 3. 

12. Penzoldt. In Penzoldt-Stintzing, Handbuch d. spec. Therapie innerer 

Krankheiten, Bd. iv, S. 514. 

13. Rosenheim. Pathologie u. Therapie der Krankheiten d. Darmes, 1893, 

S. 511. 

14. Wegele. Diatetische Behandlung d. Magendarmerkrankungen, 1896, S. 

107. 

15. Williams. Boston Medical Journal, Aug. 23, 1888. 

16. Lauder Brunton. Wiener med. Blatter, 1896, Nos. 37-39. 

17. C. A. Ewald. Berliner Klinik, 1897, S. 16. 

18. von Liebermeister. Yorlesungen iiber specielle Pathologie u. Therapie, 

Bd. v, S. 168. 

19. Fleischer. Lehrbuch d. inneren Medicin. 

20. Hiller. Zeitschr. f. klin. Medicin, 1882, Bd. iv, S. 481. 

21. Kohlstock. Charite-Annalen, 1893, Bd. xvii. 

22. Wood. The Therapeutical Gazette, Jan. 15, 1895. (Cited from Arch. f. 

Verdauungskrankheiten, Bd. i, S. 320.) 

23. Eakins. The Australian Med. Gaz., Jan. 15, 1895. (Cited from same 

source as 22.) 

24. Scarpinato. Arch, fermacolog. e therap., March 1, 1896. (Cited from 

Arch. f. Verdauungskr., Bd. ii, S. 396.) 

25. Virchow. Virchow's Archiv, 1853, Bd. v, S. 281. 

26. Leichtenstern. von Ziemssen's Handbuch, Bd. vii, Heft 2, Aufl. 2, S. 

509 u. f. 

27. Curschmann. Deutsches Arch. f. klin. Medicin, 1894, Bd. liii, S. 1. 

28. Fleiner. Mtinchener med. Wochenschr., 1895, Nos. 42-45. 

29. von Leube. von Ziemssen's Handbuch, Bd. viii, H. 2, Aufl. 2, S. 242. 

30. Boas u. Levy-Dorn. Deutsch. med. Wochenschr., 1898, No. 2. 



CHAPTER XVI 

ULCEUS OF THE INTESTINES 

Introductory Remarks. — An extraordinary variety of ulcers 
occur in the intestinal canal. It is unnecessary to describe them 
all in this chapter, as many are only complications or localizations 
of diseases which do not fall within the province of this work. 
Such, for example, are the ulcerations accompanying acute infec- 
tious diseases (typhoid fever, acute dysentery, diphtheria, anthrax, 
sepsis, erysipelas, variola, puerperal fever, leprosy), as well as con- 
stitutional diseases (gout, scurvy, leucaemia). The toxic ulcerations 
from mercury, arsenic, antimony, as well as the so-called uraemic 
ulcers, bear such slight relations to intestinal pathology that there 
is no necessity for describing them here. There remain only those 
forms of ulceration which, from their clinical symptoms, pursue an 
independent course. These are, naming them in the order of their 
frequency : the catarrhal ulcer, the follicular ulcer, the stercoral 
ulcer, the tuberculous ulcer, the chronic dysenteric ulcer, the syphi- 
litic ulcer \ the amyloid ulcer, and finally the embolic and thrombotic 
ulcer. The duodenal ulcer, a peculiar clinical type, will be de- 
scribed separately, and in that connection a few remarks will be 
made on ulcers due to burns. 

Catarrhal and follicular ulcers are tolerably often observed in 
intestinal catarrhs. Their favorite location is the large intestine, 
and it is only exceptionally that they are found higher up. They 
owe their origin to slight losses of epithelium, which permit of the 
entrance of organisms which excite inflammation, or of substances 
which are chemical irritants. The superficial strata of the mucous 
membrane break down and a superficial erosion develops ; if the 
process goes on, an ulcer of more or less depth may be formed 
which may penetrate to the serous coat, and terminate in perfora- 
tion. Several small ulcers may become confluent and give rise to a 
single large one. If the ulcer heals, subsequent cicatricial contrac- 
tion may lead to intestinal stenosis. 

20 293 



294: DISEASES OF THE INTESTINES 

The follicular ulcers originate primarily from an inflammation 
of a follicle (suppurative follicular enteritis), in which the swelling 
gradually increases, suppuration and rupture occur, with resulting 
loss of substance — the follicular ulcer. Sometimes these points are 
so numerous that the mucous membrane presents a sievelike appear- 
ance. From undermining of the mucous membrane, these ulcers, as 
in the variety just mentioned, may coalesce to form larger ones of 
sinuous form. 

The stercoral ulcer, or the decubital ulcer of Grawitz, is found 
almost exclusively in the large intestine, and especially at those 
points at which the pressure of the fseces is most marked — at the 
flexures of the colon, in the caecum, the sigmoid flexure, the rec- 
tum, and very frequently in the vermiform appendix. In the latter 
situation it may, under certain circumstances, give rise to perityph- 
litis. Stercoral ulcers are frequently seen to develop above ste- 
nosed portions of the intestine. The} 7 may be superficial or deep, 
and lead to extensive loss of substance with suppuration. If they 
heal, stenosis may follow from cicatricial contraction, but extensive 
strictures secondary to stercoral ulcers are of great rarity. 

The tuberculous ulcer is by far the most important variety, and 
the one which has been most carefully studied. A distinction is- 
made between primary intestinal tuberculosis, which develops in 
the intestine of an individual who has heretofore been free from 
tuberculosis, and secondary intestinal tuberculosis, which arises in 
connection with some other tuberculous affection. The occurence 
of primary intestinal tuberculosis is still disputed by Klebs 1 and 
von Leube 2 ; but at the present day we must admit that unim- 
peachable observations (Behrens 3 , Eisenhart 4 , Wyss 5 , Melchior 6 } 
have demonstrated that it may rarely occur in older children and 
adults. In earliest childhood intestinal and mesenteric tuberculosis 
is of very frequent occurrence. Investigations, particularly those 
of Bollinger and his pupils, give convincing evidence that this form 
of tuberculosis should be regarded as dietary (milk and the flesh of 
tuberculous cows). 

Secondary intestinal tuberculosis, on the other hand, is one of 
the most frequent complications of pulmonary tuberculosis. Ac- 
cording to the statistics of Eisenhart 4 , based upon 1,000 autopsies, 
it was present in 56.3 per cent. Other authors, such as Hamann 7 , 
find the percentage to be higher ; and Herxheimer 8 states that in 
58 cases there was only 1 in which tuberculous disease of the intes- 
tine could not be found. The mode of origin of intestinal tubercu- 



ULCERS OF THE INTESTINES 295 

losis, long ago attributed by Klebs to the swallowing of tuberculous 
sputum, is now recognised to be an auto-intoxication with material 
containing bacilli. This may even be proved in an indirect way 
from the statistics of Eisenhart. In them it appears that out of the 
1,000 autopsies on [all varieties of] tuberculous patients, of whom 
567 were cases of intestinal tuberculosis, there were only 3 cases 
in which the intestinal tuberculosis was not associated with pulmo- 
nary tuberculosis. Infection of the intestine by the tubercle bacil- 
lus naturally results if erosions are present ; the researches of Orth 9 
are especially instructive on this point. But it is important to note 
that, according to the investigations of Fischer 10 , Dobroklonsky n , 
Tschitschowisch 12 , and others, tuberculosis may be conveyed to the 
mucous membrane of the intestine even when its epithelium is intact. 
Tuberculous lesions are not distributed uniformly throughout 
the intestines ; some regions — the lower part of the ileum and of the 
caecum — show a special liability to invasion. The very slow move- 
ment of the chyle in these regions is the chief cause why this is the 
site of preference. Below the caecum and above the ileum the 
development of tuberculous ulcers is much more infrequent. The 
process usually begins in Peyer's patches and in the solitary follicles. 
Small nodules are developed in them (miliary tubercles) and the 
lymph follicles become smaller. By their rupture ulcers are formed. 
Fresh eruptions of tubercle spring up from its base and in its 
neighbourhood. The original lenticular ulcers increase in size by 
coalescence, and, breaking through the muscular coat, reach the 
serous covering and sometimes penetrate into the abdominal cavity. 
The ulcers may lie with their longer axis parallel to the course of the 
intestine (longitudinal), or at right angles to it (encircling). The 
former develop in a Peyer's patch, the latter follow the course of 
the vessels ; yet some have quite an irregular outline. Tuberculous 
ulcers of the intestine exhibit in the main but a very slight tendency 
to heal. Out of Eisenhart's 4 567 cases, only 10 showed ulcers which 
had completely healed ; in 25 cases there was partial cicatrization. 
In consequence of cicatricial contraction, intestinal tuberculosis 
may produce simple or multiple stricture, in rare cases complete 
occlusion 13 . In the chapter on Intestinal Stenosis this subject will 
be taken up more in detail. Perforation of a tuberculous ulcer is 
a rare occurrence (about 5 to 10 per cent). It usually takes place 
in the caecum or vermiform appendix, and opens into a space shut 
off by previous inflammatory adhesions, and only very rarely into 
the general peritoneal cavity. 



296 DISEASES OF THE INTESTINES 

A few remarks on ileo-csecal tuberculous tumours may be intro- 
duced at this point, because they arise from tuberculous ulcerations, 
although, strictly speaking, they fall under the head of tumours. 

Our knowledge of ileo-csecal tumours is of recent date, and the 
credit for it is chiefly due to the experience gained from the opera- 
tive surgery of the intestines. Following Conrath 14 , Durante (1890) 
was the first to point out the features of resemblance and the differ- 
ences between carcinoma and tuberculous tumour of the caecum. 
In 1891, he was followed by Billroth 15 , Henri Hartmann and 
Pilliet 16 , and Salzer 17 , who laid stress upon the tuberculous charac- 
ter of the tumours in question. The excellent work of Czerny 18 , 
Konig 19 , Korte 20 , Hof meister 21 , and Conrath 14 has so far advanced 
our knowledge of the pathology and operative treatment of tuber- 
culous tumours of the ileo-csecal region that at the present day our 
clinical knowledge of them is complete in all essential details. 
From the medical side, however, they have received very little 
attention except in the paper of Obrastzow which will be alluded 
to later, so that I think a detailed consideration of the subject is 
indicated in this place. 

The tuberculous tumour (see Fig. 29) is usually the product of 
inflammatory infiltration from multiple tuberculous ulcerations. 
These partially cicatrize, with the formation of a large amount of 
scar tissue, which gradually contracts so as to cause a stenosis of the 
lumen of the intestine. It is evident that such stenosis will favour 
hypertrophy of the coats of the intestine. The contraction is 
most marked in the vicinity of the ileo-csecal valve because the 
tissue shrinkage is greatest at this point ; the valve itself is usually 
involved in the process. 

The ulceration may originate in the serous coat and extend 
deeply. Conrath attributes this to a direct infection from local- 
ized tubercular disease of the lymph glands ; while the mucous- 
membrane form is considered to be an auto-infection from tuber- 
culous sputum, or as a primary tuberculosis — a tuberculosis from 
ingesta in the stricter sense. Conrath traces the fact that ceecal 
tuberculosis usually remains localized, to several causes. One is, 
that the tubercular deposits in the subserous layer do not contain 
so many bacilli as those in the deeper strata, and thus general- 
ization is hindered. For this reason the pulmonary phthisis ob- 
served in connection with caecal tuberculosis is usually of mild 
form, and in contra-distinction to fully developed phthisis, the oppor- 
tunity for bacillary infection of the intestine is relatively small. 



ULCERS OF THE INTESTINES 297 

Evidently we must not, even in this case, lose sight of the fact that 
on account of its location the caecum affords a favourable seat for 
the deposit of tuberculous products, and most unfavourable condi- 




Fig. 29.— Tuberculosis of the Cecum. (Wolfler— Conrath.) 
a, junction of caecum and ascending colon ; J, junction of ileum and caecum. 

tions for their cure. The conditions are apparently very analogous 
to those in primary tuberculosis of the appendix, which once estab- 



298 DISEASES OF THE INTESTINES 

listed, in like manner and doubtless for the same reasons, and in 
spite of any sort of treatment, leads to progressive changes. 

The chronic dysenteric nicer develops as a sequel of the acute 
form. The symptoms may be those of an unusual prolongation of 
the disease, or they may set in shortly after apparent cure by one or 
more relapses ; or, finally, what was originally a catarrhal diarrhoea 
may terminate in dysentery. In its essential features the ana- 
tomical picture of chronic dysentery resembles that of the acute 
form, and is characterized by the formation of a variable number 
of deep-seated ulcers of the large intestine with raised and un- 
dermined edges. Accompanying this there are the symptoms of 
an intense catarrh of the large intestine. If the ulcers heal, the 
intervening isiets of mucous membrane become so much more 
prominent that they may resemble true polypi. Contraction may 
lead to stenosis, but experience shows that this is not of frequent 
occurrence. It only exceptionally happens that dysenteric ulcers 
perforate, for the serous coat over them is usually thickened by 
inflammation. In less pronounced cases the intestine shows only 
the signs of a severe catarrh with swelling or suppuration of the 
follicles, or the formation of simple catarrhal ulcers. Between these 
there exist a great variety of transition forms which sometimes fol- 
low the type of catarrhal enteritis, and sometimes of true dysentery. 

Syphilitic ulcers are extremely rare in the small intestine (they 
are most frequent in the newborn); they are more common, but 
still rare, in the large intestine ; they are most common in the rec- 
tum. Syphilitic ulcers of the large intestine are usually formed by 
the breaking down of gummata in the mucous or submucous coats. 
They begin as superficial bulbous elevations, which break down 
slowly and leave ulcers characterized by sharp borders and a yellow- 
ish, flocculent, grayish-white base. Under certain conditions they 
may coalesce, with extensive loss of substance, the tendency being 
to superficial rather than deep ulceration. Perforation into the 
abdominal cavity of a syphilitic ulcer of the large intestine has not, 
as far as I know, been described, but perforation into some neigh- 
bouring organ, especially from the rectum, is not at all infrequent. 
Stenosis of the large intestine from syphilis is very rare. For 
syphilitic ulceration of the rectum, see the chapter on Diseases of 
the Rectum. 

Amyloid ulcers, according to some authors, are rare, and accord- 
ing to others (Colberg, Courtois-Suffit, etc.) they are frequent. 
The pathological anatomists (Orth, Ziegler, Birch-Hirschfeld) speak 



ULCERS OF THE INTESTINES 299 

with great reserve concerning the occurrence of this form of ulcer. 
At the present time they have no clinical importance. 

Embolic or thrombotic ulcers arise from the occlusion of small 
twigs of the mesenteric artery, as a result of endocarditis or of 
atheroma of the large vessels. A small hemorrhagic infarct re- 
sults from the embolism, and is followed by necrosis and ulceration. 
The ulcers are located chiefly in the small intestine, from the duode- 
num down to the caecum ; below this point they are very seldom met 
with. The ulcers are of various sizes, depending upon the extent 
of the infarction. Sometimes the ulceration is very considerable, 
extending through the entire thickness of the intestinal wall, and 
perhaps leading to perforation into the abdominal cavity. Septic 
emboli from ulcerative endocarditis may cause either small hemor- 
rhages or very minute embolic abscesses between the mucous and 
submucous layers. These rupture into the interior of the intestine, 
and give rise to multiple ulcerations. 

Symptomatology of Intestinal Ulcer 

The symptoms of intestinal ulcers are very varied, and depend 
not only upon the kind, but upon the localization, the number, 
and the extent of the ulcerative processes. It must be kept in 
mind that, as a rule, a more or less intense catarrh accompanies 
every form of ulceration. The changes in the stools thus produced 
(constipation, diarrhoea, mucous stools, bloody stools) in turn favour 
the progress of the ulceration and hinder cicatrization. We have 
therefore to consider a variety of conditions which, to a very con- 
siderable degree, must influence and modify the clinical picture of 
intestinal ulceration. In the first place, there are no distinctive signs 
for the differentiation of the various kinds of ulcers. Even the 
recognition of tubercle bacilli in the stools — to repeat what we have 
already emphasized (page 120) — has only a very limited significance. 
For this reason a separate symptomatology of the various forms will 
be omitted, and the discussion will be limited to the characteristics 
which they possess in common. 

It is undoubtedly true that ulceration frequently occurs without 
any symptoms whatever. Every physician who has been present 
at many autopsies in cases of phthisis has observed intestinal ulcera- 
tion, sometimes of considerable extent, which had caused no appre- 
ciable symptoms during life. This is also true of amyloid degen- 
eration of the intestine with ulceration, and especially so for stercoral 
ulcers, as well as for the catarrhal and follicular forms. It is difii- 



300 DISEASES OF THE INTESTINES 

cult to determine whether there may not have been slight subjective 
symptoms (constipation), and changes in the stools (admixture with 
blood, mucus, or pus). The clinical history gives us little positive 
information. In the majority of cases of ulceration, however, there 
are symptoms which permit the diagnosis to be made in some cases 
with likelihood, and in others with certainty. 
We shall next describe : 

(a) The Subjective Symptoms. — The most important symptom is 
pain. As has just been mentioned, pain may be entirely absent in 
ulcer of the intestine. When it is present, it does not give us any 
clew to the variety or location of the ulcerative process. Though 
the patient be intelligent, his statements as to the subjective sensa- 
tions of pain are very vague, and it is only exceptionally that they 
serve to indicate the location of the process. The objective sensi- 
tiveness on pressure is more valuable. This tenderness seems to 
me to be most marked in severe forms of intestinal tuberculosis, 
and in some cases I have found it localized and very persistent in 
the region of the umbilicus. It has to be distinguished from the 
tenderness of chronic dysentery, which is more diffuse and extends 
over the descending colon and sigmoid flexure. In my experience 
this too may be absent. The intensity of the pain is of some impor- 
tance in estimating the extent of the ulcer and the progress which 
it is making toward the external surface of the intestine. In cases 
of very decided tenderness deep ulceration may with circumspection 
be thought of. 

(b) The Objective Symptoms. — Of these, the nature and condi- 
tion of the evacuations from the bowels are of chief importance. 

In cases of well-marked ulceration of the bowel the passages may 
be normal, or there may be constipation. It is important to re- 
member this in passing judgment on individual cases. 

The younger Frerichs describes two very instructive cases in his Contribu- 
tions to the Study of Tuberculosis (1882). They were both cases of pulmonary 
consumption. One of them had a profuse diarrhoea w T ith elevation of tempera- 
ture, so that a diagnosis of typhoid was made. The other patient w^as persist- 
ently and obstinately constipated. In both cases the autopsies showed that the 
cause of the bowel symptoms was a widespread intestinal tuberculosis. In the 
second case, in addition to the tuberculosis of the ileum, there was exten- 
sive tuberculous ulceration of the colon. 

Nothnagel advances a plausible hypothesis to account for these 
cases, viz., that the destructive process has either completely de- 
stroyed the nerves in the base of the ulcer, or that the continuous 



ULCERS OF THE INTESTINES 301 

irritation has exhausted their sensitiveness to the usual stimuli. The 
stools usually show marked deviations from the normal ; there is 
diarrhoea, or diarrhoea alternating with constipation. It is very 
probable that the seat of the ulceration has an influence in deter- 
mining which of these conditions will predominate, since experi- 
ence has shown that diarrhoea is less frequent when the ulceration 
occurs high up than when it is below the ileum. As has already 
been said, the existence of a simultaneous enteritis has an extremely 
important, perhaps the most important, influence. For instance, 
there is scarcely ever any severe diarrhoea in ulcer of the duodenum, 
because the process is a localized one, and therefore the catarrhal 
condition is limited to a very small portion of the intestine. 

The presence of abnormal constituents, such as blood, pus, and 
shreds of necrotic tissue, is more important than the consistence of 
the stools. Blood may be present in various forms : as fresh or 
decomposed blood, or intimately mingled with the dejections, yet 
recognisable by the eye, or, finally, only to be detected by the micro- 
scope. The old maxim that blood from the upper part of the intes- 
tinal canal is materially altered in appearance when voided is true, 
as a rule, in ulceration of the intestine. But, as every one knows 
from the pathology of typhoid ulcer, blood which is unchanged may 
come from the subdivisions of the small intestine, provided it is 
quickly expelled. Blood is always passed in an unchanged condi- 
tion when it comes from the lower part of the small intestine or 
from the colon, and, according to the amount of the hemorrhage, 
appears as an enterorrhagia, or is intimately mingled with the 
dejections. Smaller hemorrhages are usually easily recognised in 
the same way ; minute ones only by microscopic, chemical, or spec- 
troscopic methods. 

Hemorrhages are not, however, a necessary symptom of intes- 
tinal ulcer. In dysenteric and typhoid ulcers they are very fre- 
quent, and in tuberculous and catarrhal ulcers relatively infrequent. 
In tuberculosis of the intestine, according to Girode 22 , the stools 
often have a dark colour, similar to the coffee-ground vomit of gas- 
tric cancer ; and this he attributes to repeated oozing of blood from 
the ulcerations. I have observed the same appearances, but they 
do not afford conclusive proof of the presence of blood. 

Admixture of pus in the faeces is a very important symptom of 
intestinal ulcer. However, the finding of pus is not absolutely con- 
clusive, since it may come from some abscess in the neighbourhood 
which has ruptured into the bowel, or may occur in croupous or 



302 DISEASES OF THE INTESTINES 

dysenteric conditions, or from ulcerating tumours of the bowel. 
For this reason, as I know from personal experience, the diagnosis 
may become extremely difficult. It is very important to ascertain 
whether the pus is voided pure or mixed with blood. In the former 
case it points to the presence of an abscess adjacent to the intestine, 
while in the latter it indicates that the pus has originated in the 
bowel itself. Aside from this consideration, it may be stated that 
the presence of pus makes intestinal ulceration in the highest degree 
probable. On the other hand, its absence does not negative the 
existence of ulceration. 

Like the gastric contents in ulcerating carcinoma, the passages 
acquire a penetrating fetid odour when mixed with large quan- 
tities of pus. This differs so characteristically from the normal 
odour of the faeces that it can scarcely be forgotten by one who 
has ever appreciated it. The importance of this sign lies in the 
fact that purulent stools may often be detected in this way when a 
formal inspection has been neglected. In many cases the unaided 
eye suffices to determine the presence of pus. Small quantities of 
pus can only be recognised by the microscope ; but, if the fseces 
are spread out on a black dish, yellowish-green specks, of the size 
of the smallest millet seeds, will sometimes be seen and recognised 
as pus. 

Fragments of intestinal tissue* when present, are always the 
result of necrotic processes, and are found only in acute and sub- 
acute dysentery. It has often been asserted that the presence of a 
formation resembling frog spawn or sago grains is characteristic of 
intestinal ulceration. But there is now no doubt that Yirchow was 
right when he declared that these are vegetable products, which 
may be found in the stools in a great variety of conditions. Of the 
intestinal bacteria, the tubercle bacillus is the only one which has 
any, and even that a very limited, significance. In the General 
Section we have discussed the diagnostic value of the presence of 
the tubercle bacilli, and it is sufficient to repeat that it is only 
their continuous absence from the sputum and constant presence 
in large numbers in the stools which justifies any positive conclu- 
sion. In tuberculosis of the rectum a doubtful diagnosis may be 
made certain by the removal of material containing bacilli from 
the ulcer itself. 

(c) Meteorism. — This may accompany intestinal ulceration, and 
is seen fairly often in tuberculosis of the bowel and in dysentery. 
In other forms of ulceration I have not found meteorism a con- 



ULCERS OF THE INTESTINES 303 

stant symptom, unless there existed also some narrowing of the 
lumen of the bowel. In the above-mentioned varieties (e. g., tuber- 
cular and dysenteric ulceration) meteorism may, of course, be con- 
sidered a sign of intestinal paresis. 

(d) Fever. — Fever is not present in simple ulceration of the 
intestine — i. e., in the catarrhal or follicular forms. But irregular 
fever is a very important clinical symptom of dysenteric and tuber- 
cular ulcers. Sloughing carcinomata, as has been mentioned in the 
chapter on that subject, may cause an irregular and sometimes very 
marked pyrexia ; the same is true of para-intestinal abscesses. 

(e) The Urine. — Up to the present time the examination of the 
urine has not been of any special importance. The interesting rela- 
tion that exists between ulceration of the intestine and albumosuria 
after the administration of peptone in tubercular ulceration of the 
intestine (see page 135) is worthy of further investigation. Under 
some circumstances, the Ehrlich diazo reaction may be of service in 
differential diagnosis (see p. 276). 

(f) The general health may suffer markedly from the fever, 
hemorrhages, and suppuration, as well as from the diarrhoea. I 
have, however, seen patients who, in spite of frequent suppurations, 
remained well nourished. That this feature depends chiefly on the 
primary cause needs no explanation. 

The symptomatology of ileo-ccecal tumours may be introduced 
in this place. 

The age and sex are of importance. According to Conrath's 
collection of 85 cases, the frequency of tuberculosis of the caecum is 
pretty nearly the same in both sexes. Much more than one half 
(65 per cent ) of the cases were between the ages of twenty and forty 
years. Very few were found in the fifth and sixth decades. From 
Conrath's statistics there is a significant preponderance of females 
between the ages of twenty and thirty, while in those between thirty 
and forty the proportion of males is markedly greater. Caecal tuber- 
culosis usually begins insidiously, or has no characteristic symptoms. 
There may, for example, be constipation, alternating perhaps with 
diarrhoea, but there is nothing to indicate that an incurable destruc- 
tive process has begun. There is no change in the picture until the 
characteristic phenomena of stenosis or a tumour become manifest. 
The distinctive signs of chronic stenosis of the bowel develop — the 
occasional attacks of colic with nausea or vomiting, the visible 
tetanic contractions of the intestine, the constipation persistent in 
spite of the usual remedies, and, as a result, a severe loss of nutri- 



304 DISEASES OF THE INTESTINES 

tion. In prolonged cases the marasmus is as marked as the cachexia 
of cancer. Occasionally there may be hemorrhages from the bowel, 
or blood may be mixed with the stools. As the disease is usually 
associated with a manifest or incipient pulmonary phthisis, irregu- 
lar fluctuations of temperature are frequently observed. 

The most important symptom of csecal tuberculosis is the 
tumour. Its size varies ; it is usually made more accessible to 
palpation by filling the rectum with water. At first the tumour is 
more or less movable, but later it may become quite fixed by adhe- 
sions or thickening of the mesentery. Under such conditions it 
may lie immediately under the abdominal wall, and thus lead to 
serious mistakes in diagnosis. Furthermore, it may suppurate, 
break down, and rupture externally, forming an artificial anus ; or 
the abscess may perforate into the abdominal cavity, or into one of 
the neighbouring organs. 

The course of cgecal tuberculosis is usually slow. Many cases 
lasting two or three years have been observed. As the tumour 
doubtless has a long period of latency, the beginning of the disease 
evidently dates much farther back. 

Under medical treatment the prognosis is unfavourable. The 
stenosis of the bowel gradually increases until there is absolute 
obstruction or perforation into the abdominal cavity or adjacent 
organs. Death may be caused by pulmonary phthisis, peritoneal 
tuberculosis, by disseminated tuberculosis of the intestine, by the 
protracted suppuration of multiple abscesses, by amyloid changes in 
the intestines or kidneys, or by other complications. 

Diagnosis and Differential Diagnosis 

The detection and identification of ulcers of the intestine pre- 
sent many difficulties. One, already alluded to, is that many forms 
run a perfectly latent course or give but slight clinical symptoms. 
A second difficulty, which has also been mentioned, is that the dif- 
ferent forms have no specific characteristic signs. With few excep- 
tions, a positive diagnosis can only be made when the other clinical 
facts clearly show the relationship between and etiology of the symp- 
toms. On the other hand, it occasionally happens that, although 
the standard symptoms are absent, one may suspect ulceration of 
the intestine when disorders of the functions of the bowels, pro- 
nounced tenderness, diarrhoea, and marked impairment of the general 
health are suddenly or gradually added to the previous symptoms. 
Even in such a case, however, the disease may only be suspected. 



ULCERS OF THE INTESTINES 305 

The recognition of ulcers of the small intestine, especially those 
which are not tuberculous, is especially difficult. The changes in 
the stools may perhaps consist in hemorrhage or melsena. The 
presence of pus can not be depended upon because, as von Leube 2 
has shown, pus loses its characteristic appearance in passing through 
the colon. It is unnecessary to say that hemorrhages from the 
intestinal canal may have a great variety of causes. In a few cases, 
as in those reported by Nothnagel 23 , the diagnosis of embolic and 
thrombotic ulcers has been successfully made, and is of course pos- 
sible when the source of the embolus can be clearly traced. This 
may be possible when endocarditis, pyaemia, or arterial sclerosis has 
preceded, or when the symptoms of embolism of a branch of the 
mesenteric artery (severe colicky pains, severe hemorrhage setting 
in at once, meteorism, intestinal paralysis) have been present and, 
what is of course very rare, have abated. 

The prospect of recognising ulcers of the large intestine (ex- 
clusive of the rectum) is better, because the excreted products are 
accessible to direct and repeated examination. Aside from the 
changes in the consistence of the stools and the local pain and ten- 
derness (whose value must be estimated with care), the main factors 
to be looked for are admixtures of blood, pus, mucus, and tissue 
debris with the faeces. Naturally, the presence of both blood and 
pus is of the highest importance, while, as already explained, either 
of them alone leaves room for many possibilities. The diagnosis 
is not complete until not only the presence of an ulceration is de- 
termined, but its special causation made out. In a few instances, 
in addition to pulmonary tuberculosis, dysentery, and typhoid fever, 
there are no special difficulties in reaching a conclusion, but there 
are varieties which present insurmountable difficulties. 

I shall relate one case in which the diagnosis of tuberculous 
ulceration of the large intestine was probable, and another in which, 
although ulcer of the intestine was diagnosed with positiveness, the 
etiology of the ulcer was never cleared up. 

Case I. — Miss Clara St., of Radenickel, near Crossen ; twenty-eight 
years old. 

Previous History. — Father had chronic pulmonary disease — otherwise no 
hereditary taint could be made out. The patient has been weak and sickly 
from her youth. Began to menstruate at fourteen ; is regular, with very profuse 
flow. Six years ago, without any exciting cause, in particular without any 
previous cough, moderate haemoptysis. This was repeated every four to six 
weeks. Two years later began to have pains in the epigastrium, which her 
physician attributed to gastric ulcer. She was sent to Carlsbad. Here she 



306 DISEASES OP THE INTESTINES 

had hemorrhages from the stomach arid melaena. In the following year 
haemoptysis returned every four to six weeks. No change occurred until Oc- 
tober, 1896, since which time there has been no haemoptysis. 

The present illness developed shortly before Christmas, 1897. It began 
with a sudden attack of severe pain in the region of the umbilicus, lasting day 
and night, not dependent upon the ingestion of food, and increased by pres- 
sure. Six weeks later there was a sudden discharge of pus from the rectum, 
preceding a normal passage. The pus coated the faecal masses superficially. 
This discharge of pus was repeated four weeks later, the pains having mean- 
while ceased. From that time on evacuations of pus continued at intervals of 
four to six weeks. During this period there were attacks of pain in the region 
of the intestines, but not simultaneously with the purulent discharge. These 
attacks used to last for a few weeks and then disappear for a few months. 

Since May, 1898, the purulent discharge has been constant. There has been 
a normal painless stool every day. There are frequent cramplike pains, occur- 
ring only at night. By the end of May, bright fluid blood began to appear 
with the pus. This gradually increased in amount. Since the middle of June, 
1898, the stools have been preceded by clear blood, and followed by blood with 
a little pus. During the last few days, neither pus nor blood has been passed. 

Present Condition. — The patient is poorly nourished; the cheeks and lips 
are pale. Pulse, 72, of moderate tension. No fever. Nothing of especial in- 
terest in the lungs. The abdomen shows no abnormal resistance, no increased 
meteorism, no tenderness anywhere. Urine, negative ; in particular, no indi- 
can. Examination by the vagina and rectum, negative. 

Stools, solid and of normal calibre. 

Irrigation of the bowel gave a negative result. 

On June 30, 1898, she had a movement consisting of well-formed faecal 
masses coated with muco-purulent shreds, in which pus cells were demonstrated 
in abundance by the microscope. Repeated examination failed to show tuber- 
cle bacilli. Digital and ocular examination of the rectum resulted negatively. 

There is no doubt that ulcers were present in this case. It is 
most probable that they were located in the descending colon or 
the sigmoid flexure. In spite of the absence of signs of pulmonary 
lesions and the failure to find bacilli, the diagnosis of tuberculous 
ulceration of the large intestine is probable from the previous his- 
tory of repeated haemoptysis and the hereditary taint. 

Case II. — Max B., clerk; age, twenty-eight years. Was perfectly healthy 
until 1895. In July of this year he acquired gonorrhoea, followed by stricture, 
which was treated with sounds and cured. In April, 1898, had another attack 
of gonorrhoea which lasted three weeks. During this period he states that he 
had " catarrh of the bladder." He had a chancre at the same time, which 
lasted fourteen days. Whether this was a soft chancre or an initial lesion, the 
patient does not know positively; but, at any rate, he was treated without 
mercurial inunctions by a specialist. 

As early as January, 1897, the patient noticed for the first time bleeding 
from the bowel, the cause of which he does not know. There had been no 



ULCERS OF THE INTESTINES 307 

antecedent constipation of notable degree. During this period he had twelve 
movements from the bowels each day, fluid, and mixed with blood. He does 
not know whether they contained any pus. There was no pain, either sponta- 
neous or during defecation; and the actual loss of blood, in his opinion, was 
less than at the present time. Under the treatment which the patient received 
from January until July, the diarrhoea gradually ceased, the blood continued to 
appear from time to time, even when the stools were normal otherwise, and 
finally even this ceased. From that time until October, 1898, he had no abnor- 
mal symptoms. The treatment was by internal remedies. 

The patient now appears, complaining that he has four to five diarrhceal pas- 
sages per day which contain blood and mucus. He has tenesmus, and a fluid 
resembling bloody mucus frequently escapes without fasces. There is no pain. 
He has a good appetite, is easily satiated, but hunger returns in a short time. 
However, he does not feel in any wise ill. 

Present Condition. — A moderately well-nourished young man of slender build, 
who looks healthy. An examination of the thoracic viscera shows them to be 
absolutely normal ; there is no ground for suspecting pulmonary phthisis. The 
abdomen is nowhere distended, gives no abnormal percussion resonance, and is 
nowhere sensitive to pressure. Digital examination of the rectum gives quite 
normal results, confirmed by repeated visual examination. There are no signs 
of syphilis. There is no swelling of the glands, no leucoplakia, no atrophy of 
the base of the tongue, and there are no nodules. (In response to an inquiry, 
the specialist who treated the case in 1898 says that it was undoubtedly a soft 
chancre.) The urine contains neither sugar, albumin, indican, nor peptones. 
The patient was directed to bring a sample of his passages at each visit. 

The examination of the faeces, which was made on an average two or three 
times in each of the following weeks, showed that they were of normal colour, 
partly formed, but mainly pulpy. There was a slight superficial admixture of 
bright-red blood and a large admixture of greenish-yellow pus which settled in 
a thick layer at the bottom of the glass. There was no intimate mingling of 
the pus and blood with the fasces, and no further abnormal changes could be 
made out upon microscopic examination. Repeated examinations for gonococci 
and tiibercle bacilli were invariably negative. 

The treatment consisted at first in suitable diet, all irritating substances 
being excluded. Under irrigation with chamomile tea, and subsequently with 
a solution of tannic acid, the diarrhoea improved somewhat, but the blood and 
pus continued in variable quantity. There was no pain, either spontaneous or 
on pressure. Irrigations with a solution of nitrate of silver, 1 to 1,000, were tried, 
but had to be abandoned before long because they increased the diarrhoea, and 
the patient complained of burning sensations in the rectum and sigmoid 
flexure. Illumination of the rectum, the patient being in the lithotomy posi- 
tion, again failed to give any positive result. 

December 10, 1898. — The blood and pus in the stools have increased. Pa- 
tient says that on alternate mornings he has four or five movements of the bowels 
following close upon each other ; they contain a considerable amount of pus ; 
and that on the intervening days the conditions are nearly normal. 

December 18th. — Enema of subnitrate of bismuth in suspension, preceded 
by a cleansing enemata of chamomile tea. 



308 DISEASES OF THE INTESTINES 

December 29th. — Has only one or two movements from the bowels daily, of 
thin, pasty consistence and still containing blood and pus in variable quantity, 
but always enough to be recognised by the naked eye. 

January 17, 1899. — Patient feels very well. One or two movements from 
bowels daily. They still contain blood and pus, but in smaller quantity. No 
pain. Abdomen not tender on palpation at any point. Slight meteorism on 
percussion below the umbilicus. 

In this case also, the diagnosis of ulceration of the large intes- 
tine is a safe one ; but it is not possible to determine the nature 
of the process (whether chronic dysentery, follicular ulcer, or tuber- 
culous ulcer). There could not have been a follicular or catarrhal 
ulceration at the bottom of this case, for the suppuration was too 
extensive; and there was besides an absence of a long-continued 
antecedent catarrh to act as a predisposing cause. 

In the diagnosis of ileo-csecal tuberculosis, the following points 
should be considered : The recognition of a tumour in the ileo- 
csecal region, the youth or middle age of the patient, the presence 
of pulmonary or other localization of tuberculosis, a long duration 
of the symptoms, emaciation and pallor, the presence of tuberculous 
processes in other organs (lungs, joints, etc.), and, finally, the exist- 
ence of an intestinal stenosis having the features first described by 
Konig 19 . They are the following : The abdomen is distended ; fre- 
quently there is visible peristalsis, accompanied by gurgling, splash- 
ing, sometimes musical sounds, especially in the neighbourhood of 
the csecuin. Toward the end of an attack the sounds heard resemble 
those produced by expelling the last drops from a syringe ; the ab- 
domen collapses and the attack is over. According to Konig, these 
peculiar manifestations depend upon the relation between the length 
and the tightness of the stricture, the hypertrophy of the portion of 
the intestine above the constriction, and the relaxation of the gut 
below it. In such cases Ehrlich's diazo reaction gives important 
confirmatory evidence, for the extended investigations of Krokie- 
wicz 24 have demonstrated that this reaction is almost invariably 
negative in carcinoma of the digestive tract, while it is seldom 
absent in tuberculosis. In addition, as Obrastzow ^ has shown, the 
finding of tubercle bacilli may fortify the diagnosis. Aside from 
carcinoma, a differential diagnosis must take into consideration the 
possibility of exudations in the ileo-csecal region, especially peri- 
typhlitis, and also various rare forms of tumour (sarcomata, fibrom- 
ata, foreign bodies, intussusception, faecal tumours, actinomycosis, 
pericolitis, tumours consisting of abnormally located or displaced 



ULCERS OF THE INTESTINES 309 

segments of the bowel, etc.). It is impossible to enter into a full 
discussion of all these sources of error, and these hints, although 
they by no means exhaust the possibilities, must suffice. The dif- 
ferential diagnosis between carcinoma and tuberculosis of the caecum 
calls for special notice. Experience teaches us that it is very diffi- 
cult. None of the above criteria, even the finding of tubercle 
bacilli, insures us against error. Only a collective consideration of 
the signs of csecal tuberculosis warrants a decision. The following 
table will be of service, though, like all such schematic presenta- 
tions, it has only a limited value : 

Tuberculosis of the Caecum Carcinoma of the Ccecum 

Age : Usually the second to fourth Seldom before the fourth decade. 

decades. 

Duration : Extremely chronic. Duration that usual for carcinoma. 

Lungs : Frequently more or less pro- Examination of the lungs negative. 

nounced tuberculosis. 

Tumour: Considerable extension in the The tumour has a definite outline, 

length of the intestine ; the infiltra- which is usually strictly limited to 

tion can be shown by palpation to that of the caecum. The latter can 

involve the bowel. not be felt as such. 

Symptoms of stenosis : Always present ; Symptoms of stenosis may be entirely 

distinguished by remarkable mur- absent; when present, are usually 

murs. less pronounced than in caecal tuber- 
culosis. 

Condition of the stools : Blood and pus Blood and pus are not infrequently 

very seldom ; tubercle bacilli very found ; never any tubercle bacilli. 

often present. 

Fever : Not infrequently observed. Fever exceptionally present. 

Urine : Ehrlich's diazo reaction is Diazo reaction always negative. 

present. 

Treatment of Intestinal Ulcers 

In the treatment of intestinal ulcers, other than those of the 
rectum, the curative measures at our command are few in number. 
The weapons which asepsis and antisepsis have furnished so abun- 
dantly for the cure of external ulcers are useless in the treatment of 
intestinal ulceration. Since we lack an agent which has an efficient 
and lasting influence upon the intestinal juices and the intestinal 
contents, we can not even fulfil the simple postulate of nihil nocere. 
The only thing we can do is to avoid strong irritants, and restore 
the functions which have been perverted by the ulceration or its 
accompanying catarrh to normal. 

This is especially true of ulcers of the small intestine, and among 
21 



310 DISEASES OF THE INTESTINES 

these of the tuberculous. Here our chief task lies iu the control 
of the diarrhoea, partly by diet (see page 224) and partly by the 
astringent agents already described (page 191). "We again call at- 
tention to the favourable action of the preparations of chalk, either 
alone or in combination with bismuth (dermatol, beta-naphthol- 
bismuth, etc.). In some cases of severe tuberculous diarrhoea in 
which the diagnosis of ulceration was made with as much positive- 
ness as it can be at the present day, I have been able to keep the 
profuse evacuations at least temporarily under control by rest in bed 
and anti-diarrhceal diet. It is hardly necessary to state that this 
treatment is sometimes ineffectual, 

In ulceration of the large intestine the results are more favour- 
able, as we may supplement diet by direct local treatment with 
suitable irrigations. This measure, however, should not be valued 
too highly, since the agent is only briefly in contact with the dis- 
eased area, and the reaction of the bowel to various drugs is found 
by experience to be very much increased. Besides, in chronic diar- 
rhoea it is not possible to keep the intestine in a clean condition. 
These are all factors which make the utility of local treatment, at 
least in severe cases, to some degree problematic. Nevertheless, the 
indication in every case is to try suitable disinfecting and astringent 
drugs : such are boric acid, 3 per cent ; salicylic acid, 3 per cent ; 
salicylate of soda, 5 per cent ; nitrate of silver, 0.2 to 0.5 to 1 per 
cent ; tannic acid, 0.5 to 1 per cent. In some cases I have seen 
decisive results from bismuth injections given in similar way to 
Fleiner's method in gastric ulcer. I use one teaspoonful to one 
quarter litre of water. On account of the absence of any irritating 
quality, I prize this drug above all others, and recommend that it 
be given the preference. 

The treatment of ileo-ccecal tuberculosis is surgical. The re- 
sults are temporary, of course, since no small number of the patients 
sooner or later fall victims to pulmonary tuberculosis. Of 86 cases 
reported by Conrath 14 , the 23 operated on were found to be in good 
health one to four to eight years later. Judging from experience, 
the dangers of the operation are not inordinately high. According 
to Conrath, in 86 operations the mortality was only 16 per cent. 
The surgical procedures that have been tried are the extirpation of 
the tumour by resection of the intestinal wall, or by intestinal anas- 
tomosis (after Maisonneuve), or without extirpation the complete 
exclusion of the involved segment (division of the ends of the ex- 
cluded portion of gut after the method of Salzer). Experience 



ULCEES OF THE INTESTINES 311 

shows that entero-anastomosis offers the best chance of recovery 
(Conrath's statistics give 10 cases without a death), and the results 
otherwise are equally as good as after extirpation. In the future it 
should be the operation of preference. 

LITERATURE 

1. Klebs. Pathologische Anatomie, 1869, Bd. i, S. 256. 

2. von Leube. von Ziemssen's Handbuch, Bd. vii, Abth. 2, 2te Aufl., 1878, 

S. 310. 

3. Bebrens. Ueber primare tuberculose Darminfection des Menschen. Inaug.- 

Diss., Berlin, 1894. 

4. Eisenhardt. Ueber Haufigkeit u. Vorkommen d. Darmtuberculose. Inaug.- 

Diss., Mtinchen, 1891. 

5. Wyss. Correspondenzbl. f. Schweizer Aerzte, 1893, No. 22. 

6. Melchior. Cited from Virchow-Hirsch's Jahresber., 1890, Bd. i. 

7. Hamann. Statistik der Tuberculose im Alter von 16-19 Jahren. Inaug.- 

Diss., Kiel, 1890. 

8. Herxheimer. Deutsch. med. Wochenschr., 1885, No. 52. 

9. Orth. Virch. Arch., Bd. lxxvi, 1879. 

10. Fischer. Arch. f. experiment. Pathol., Bd. xx, 1886. 

11. Dobroklonsky. Arch, de Medecine experim., 1890, No. 2. 

12. Tschitschowisch. Annales de l'lnstitut Pasteur, III Annee, No. 5, p. 222. 

13. "Wittstock. Zur Klinik des Ileus durch Darmtuberculose. Inaug.-Diss. 

Berlin, 1893. 

14. Oonrath. Brun's Beitrage zur klin. Chirurgie, Bd. xxi, Heft 1, 1898. 

15. Billroth. Cited from Conrath, loc. cit. 

16. Pilliet. Cited from Conrath, loc. cit. 

17. Salzer. von Langenbeck's Archiv, Bd. xliii. 

18. Czerny. Brun's Beitrage z. klin. Chirurgie, Bd. vi u. ix. 

19. Konig. Deutsche Zeitschr. f. Chirurgie, Bd. xxxiv, 1892, S. 65. 

20. Korte. Ibid., Bd. xl, 1895, S. 523. 

21. Hofmeister. Brun's Beitrage, Bd. xvii, S. 577, 1896. 

22. Girode. Contribution a l'etude de l'intestin des tuberculeux. These de 

Paris, 1888. 

23. Nothnagel. Darmkrankheiten, S. 156. 

24. Krokiewicz. Wiener klin. Wochenschr., 1898, No. 29. 

25. Obrastzow. Arch. f. Verdauungskrankheiten, Bd. iv, 1898, S. 440. 



CHAPTER XVII 

BOUND TJLGER OF THE DUODENUM 

(Ulcus rotundum duodeni) 

Preliminary Remarks. — Among the ulcerative processes of the 
intestinal canal round ulcer of the duodenum demands careful atten- 
tion — anatomically, because of its size and marked characteristics ; 
clinically, because of its obscure symptomatology and diagnostic 
signs ; and because of the severe complications which may mark its 
course and appear with an extremely acute onset. 

In its most important features the pathological anatomy and 
pathogenesis of ulcer of the duodenum is the same as that of gastric 
ulcer. The extremely voluble discussion which followed Cruveil- 
hier's classic presentation of the latter subject has not solved its 
numerous problems. With reference to the mode of origin of 
chronic duodenal ulcer we also are obliged to fall back upon more 
or less well-sustained hypotheses. 

Referring the student of this subject to the text-books on dis- 
eases of the stomach, as well as to the monographs of Krauss \ Chvo- 
stek 2 , Boucquoy 3 , Oppenheimer 4 , Reckmann 5 , and Collin 6 , we shall, 
in what follows, limit ourselves to a concise description of the most 
important etiological factors which we have gathered from literature 
and from our own experience. 

In the first place, just as in the case of gastric ulcer, so pre- 
disposing and immediate causes operate in the production of the 
duodenal ulcer. As regards the predisposing causes, it is univer- 
sally, and I believe correctly, held that the corrosive action of the 
gastric acid, which is not neutralized to any essential degree until 
it meets with the pancreatic secretion, plays an important part. 
The fact that round ulcers of the small intestine occur almost exclu- 
sively in the duodenum permits scarcely any other explanation. But 
there are other predisposing causes. Dickinson 7 , and shortly after- 
ward Ferry and Shaw 8 , as well as Marmaduke Sheild 9 , have called 
attention to the appearance of duodenal ulceration in the course of 
312 



ROUND ULCER OF THE DUODENUM 



313 



chronic nephritis. Thus, from the literature of the subject, Perry 
and Shaw have collected 70 cases of duodenal ulcer, in no less than 
12 of which typical Bright's disease was present. In such cases 
everything points to a necrotizing effect exerted by the retained 
urea or its derivative, ammonium carbonate. It is apparent that in 
this case we have to deal with the same influences which produce 
multiple ursemic ulcers in the lower segments of the bowel. The 
toxic influence may act continuously or suddenly, perhaps after 
extirpation of one kidney, or after a severe acute nephritis with 
suppression of urine. 

A different set of conditions underlie those forms of duodenal 
ulcer which have been observed after extensive burns, after frost- 
bite, and in erysipelas, pemphigus, and septicaemia. The most 
likely explanation for the first-named condition seems to be that 
soluble fibrin ferment gains access to the circulation and emboli are 
formed, resulting in a partial necrosis of portions of the duodenal 
mucous membrane. On the other hand, in the case of the infective 
processes named, bacterial influences doubtless play an essential 
role. In still other cases a traumatic lesion may with more or less 
probability be looked upon as the original factor. Such cases have 
been observed by Schulze 10 , Brambillo n , Reckmann 5 , J. Pauly 12 , and 
others. Thus it may be seen that very varied causes may operate to 
produce the same anatomical changes, and it is of importance clin- 
ically to discriminate between them. 

To these etiological memoranda may be added a few brief data on 
the age and sex affected, and on the localization of duodenal ulcers. 

As far as age and sex are concerned, the duodenal ulcer shows 
striking variations from gastric ulcer. Collin, to whom we owe the 
most complete collection of cases (279), gives the following sum- 
mary : 

years 42 cases. 



Under 10 
From 11-20 
" 21-30 
" 31-40 
" 41-50 
" 51-60 
" 61-80 
" 81-94 



years 



24 
43 

52 
46 
41 
18 
13 



Of the cases occurring in the first ten years nearly one half 
(17) belong to the first year of life. Duodenal ulcer has even been 



314 DISEASES OF THE INTESTINES 

observed in newborn children who have only lived a few hours, so 
that an intra-uterine origin has been suspected. Landau 13 has 
ascribed them to thrombosis of the umbilical vein and embolism of 
the vessels of the small intestine, with consecutive necrosis. 

The infrequency of duodenal ulcer at puberty, its slow increase 
during the third decade, its marked rise in the fourth and fifth, 
and its slow falling off again in the sixth, is noteworthy. 

There is a striking unanimity among the various authors as 
regards the preponderance of the affection among the male sex. 
Collin found 205 cases out of 257, or 79 per cent, in males. This 
fact is one of the most striking in the pathology of duodenal ulcer. 
How shall we explain the fact that the male sex, which has so 
marked an immunity from round ulcer of the stomach, should show 
so peculiar a predisposition toward duodenal ulcer ? In my opinion 
the explanation can only be found in the difference in the habits of 
men and of women. Of especial importance is the fact that the use 
of alcohol and tobacco more often causes a chronic gastritis with 
marked hyperacidity in men than in women. This, however, would 
not explain why the duodenum becomes the favourite seat of ulcer- 
ation. In this connection the following considerations appear to 
me to be worthy of notice. 

Through investigations on dogs made by von Mering 14 and 
Moritz 15 , we know that the stomach expels water into the intes- 
tine with extraordinary promptness ; and further, that alcohol, sa- 
lines, dextrin, and acids, although they are absorbed by the stomach, 
are only taken up by it to a very limited extent. It further 
appears, from the investigations of von Mering, that the first dis- 
charges contain these substances in very concentrated solutioo. 
When von Mering poured 300 cubic centimetres of 25 per cent 
alcohol into the empty stomach, 105 cubic centimetres of 10.5 per 
cent alcohol flowed out within ten minutes. When he poured 200 
cubic centimetres of 50 per cent grape sugar solution into the 
empty stomach, the fluid which was carried into the duodenum 
amounted to 120 cubic centimetres, with 32 per cent sugar. In 
addition, we know from Moritz's investigations that the stomach 
first expels the fluid portions of the chyme, while the solid portions 
follow quite slowly. Furthermore, the stomach protects itself from 
highly concentrated solutions by secretion of water ; such a function 
has not yet been demonstrated for the duodenum. It thus follows 
that the duodenal mucous membrane has much less protection against 
concentrated watery solutions than the stomach, whose mucous 



ROUND ULCER OF THE DUODENUM 315 

membrane is relatively well protected against injury during the first 
stage of digestion by the slippery or solid contents. If, then, acids, 
alcohol, and saline solutions act upon a duodenal mucous membrane 
already irritated by an existing hyperacidity, it only needs an oppor- 
tune cause to produce a partial necrosis of this unresisting tissue. 
This explanation receives a further illustration from the observa- 
tions of Boucquoy 3 , Burwinkel 16 , and others, which I can confirm, 
that ulcer of the duodenum occurs with especial frequency in ha- 
bitual alcoholics. If I might cite the results of treatment as a guide 
to an opinion in this matter, I would assert that duodenal ulcer, 
although not always in classic form, is a very prevalent lesion in 
alcoholics. I shall return to this point in the section devoted to 
symptomatology and diagnosis. 

Among the features worthy of notice, we would call attention 
to the fact that duodenal ulcers, like gastric ulcers, are usually 
single. Out of 233 cases in which Collin found the number noted, 
the ulcer was solitary in 195 (83.6 per cent). Occasionally duode- 
nal ulcer is found associated with gastric ulcer or with esophageal 
ulcer. In the great majority of cases the ulcer is situated in the 
upper part of the duodenum (242 times in Collin's table of 262 cases) ; 
in not a few (74) it was adjacent to or in contact with the pylorus ; 
in 14 cases the seat was the descending portion, and in only 6 was 
it found in the inferior horizontal portion. 

There is a discrepancy in the statistics as to the relative fre- 
quency of involvement of the anterior and the posterior wall. 
Oppenheimer states that it is as 18 : 16. Collin found that out of 
127 cases in which particulars were given, the ulcer was on the 
anterior wall 71 times, on the posterior wall 45 times, on the upper 
edge 10 times, and only once on the lower edge (" Bord superieur ou 
inferieur"). In the descending portion the inner wall was most 
often involved, especially in the immediate vicinity of the papilla. 

The duodenal ulcer not infrequently gives rise to numerous 
and serious complications, which will be comprehensively considered 
further on. 

Symptomatology and Diagnosis 

In the first place, it is to be noted that a duodenal ulcer fre- 
quently runs its course without any symptoms, and that it may 
cause death by perforation into the abdominal cavity at a time when 
the patient seems to be in perfect health. Such a latent course is 
apparently more common than it is with gastric ulcer. Whether 



316 DISEASES OF THE INTESTINES 

in such cases there have not been slight symptoms extending back- 
ward over perhaps a long period is difficult to determine, but the 
fact remains that perforation is seldom preceded by severe gastric 
or intestinal symptoms. Such cases have been termed acute ulcers. 
The symptoms may be divided into subjective and objective. 

A. Subjective Symptoms 

Pain. — The pain of duodenal ulcer closely resembles that of 
gastric ulcer. It is of a burning, boring character, and radiates 
downward or to the sides, seldom or (as Burwinkel says) never 
toward the back. According to Oppenheimer, the pain is increased 
by lying on the right side. A characteristic feature of the pain 
is that it comes on several hours after the ingestion of food, and is 
localized in the right hypochondrium at a point on the prolongation 
of the parasternal line about two centimetres below the gall bladder. 
There are many exceptions to this. The pain may be more to the 
left in the pit of the stomach, in the umbilical region, or excep- 
tionally it may be more or less below this point. Judging from 
my own experience, I should also state that there is no relationship 
between the nature of the food and the onset of the pain, and also 
that the latter may persist, even begin during the fasting state — for 
example, at night. 

From observations which he made, Chvostek formulated a test 
which might serve to differentiate duodenal from round gastric 
ulcers. He found that pressing gastric pains coming on two and 
a half hours after breakfast were permanently, and similar pains 
about three hours after dinner were temporarily relieved by the 
taking of wine. He concludes from this that when the ulcer is in 
the duodenum, the taking of the wine causes a reflex closure of the 
pylorus, and thus arrests the flow of the gastric contents into the 
duodenum. This, in the case of the more abundant meal, causes a 
temporary remission, and in the case of the lighter one a lasting 
relief. But if the ulcer is situated in the stomach, the swallowing 
of wine not only does not relieve the pain, but increases it. Simi- 
larly Burwinkel 16 reports a case in which " pain in the stomach," 
beginning two or three hours after each meal, was relieved by the 
taking of an acid wine or citric acid. 

With certain limitations I have been able to confirm this sign 
in several cases of duodenal ulcer. I believe that it is dependent 
solely upon hyperacidity of the gastric juice, for we know that in 
this condition the ingestion of fluid or food will cause a cessation of 



ROUND ULCER OF THE DUODENUM 317 

the pain. Whether this comes about, as Chvostek thinks, from a 
reflex pyloric closure which for the time being prevents the passage 
of the food into the duodenum, or, as I believe, from dilution of 
the superabundant hydrochloric acid by the fluid and consequent 
diminished irritation of the ulcerated surface, may be left an open 
question. At any rate, it seems to me that the nature of the fluid 
is of no importance except that substances such as milk or egg albu- 
min, which have a strong tendency to combine with hydrochloric 
acid, should act better than, for example, wine. 

B. Objective Symptoms 

1. Points of Tenderness. — The typical point of tenderness on 
pressure coincides with the area of spontaneous pain above described, 
but, like it, may exhibit numerous variations which may easily lead 
to errors in diagnosis. As far as I know, a dorsal point of tender- 
ness has never been observed. In several cases I have noted a 
circumscribed tender point to the right of the spinal column and 
close to the twelfth dorsal vertebra. 

2. Vomiting. — When the pain is severe and long continued it 
may lead to vomiting, which is probably of a reflex nature. Strange 
to say, there are only scanty allusions to this symptom in recent 
literature. Oppenheimer found it noted 17 times in the cases (over 
100) which he collected. 

The accounts given by older authors (Albers 17 , Mayer 18 ) do 
not agree with our experience of to-day. Krauss more correctly 
observes (loc. cit., p. 59) : " In the clinical histories which I have 
collected it [vomiting] is very seldom mentioned ; it depends either 
upon stricture of the duodenum or is the result of cardialgia. In 
a few cases only is it seen in connection with dyspeptic phenomena." 
Starke 19 and Boucquoy 3 make similar statements. My own experi- 
ence, as far as it is possible to draw conclusions from a few observa- 
tions, confirms their views. 

The vomited matter has been variously described. In one ob- 
servation reported by Reckmann 5 , which in my opinion is open to 
some criticism, the vomiting occurred in three installments — the 
first pale and watery, the second bitter and sirupy (bile), and the 
third a sweetish mass (blood).* 

3. Intestinal Hemorrhage and Haimatemesis. — Profuse hemor- 
rhages from the stomach or rectum are a frequent symptom of 

* See under head of the Examination of the Gastric Contents (in Special Part). 



318 DISEASES OF THE INTESTINES 

duodenal ulcer (perhaps in one third of all the cases — Krauss, Chvo- 
stek, Oppenheimer). It is probable that this figure is too low, as 
many of the smaller hemorrhages no doubt escape observation. 
In 34 cases of hemorrhage which Oppenheimer found recorded, 
vomiting of blood occurred 8 times, malgena 10 times, and both 
hsematemesis and melaena 16 times. In all the severe cases symp- 
toms of collapse follow the escape of blood by the mouth or the 
bowel. When very copious the hemorrhage may be the imme- 
diate cause of death. It is very characteristic of duodenal ulcer 
that the intestinal hemorrhages recur at fixed intervals coincident 
with other phenomena of the ulceration. 

4. The Composition of the Gastric Contents. — There are only a 
few observations on record (von Leube 20 , Reckmann 5 , A. Robin a , 
and Devic and Roux 22 ). In the first two there was a condition of 
subacidity. In the last mentioned, a case accompanied by progres- 
sive pernicious anaemia and profuse diarrhoea, there was hyper- 
chlorhydria. The latter condition was present in one of my cases, 
though it should be stated that the examination was made a long 
time before the occurrence of the intestinal hemorrhages. Until 
more observations have been accumulated, a differential diagnosis 
on the basis of the results of examination of the gastric contents is 
not permissible ; the same opinion is expressed by von Leube. In 
three cases Robin found an entire absence of free hydrochloric acid, 
but an abundance of organic acids. Unfortunately no details are 
given as to the kind of test meal used, nor of the motor activity. 
Nevertheless Robin's results are very remarkable. 

5. There is nothing characteristic in the urine or the dejections. 

6. Icterus. — The jaundice which has been observed in a few 
cases (according to Collin, 9 out of 262) is not a specific sign of 
ulcer of the small intestine ; it belongs rather to the complications 
(see below). 

Of all these symptoms, not one per se enables the diagnosis to 
be made with certainty or even probability. Only the ensemble, the 
entire clinical history, the consideration of age and sex, is signifi- 
cant or decisive. Taking into consideration all of these symptoms 
(which are not often associated in a single case), and excluding all 
other possibilities, the diagnosis of an ulcer of the small intestine 
may be clinically made with some degree of certainty. In this view 
I agree with Chvostek, Boucquoy, and Burwinkel, but there are 
many authors who are of a different opinion (von Leube, Ewald, 
Eichhorst, Nothnagel, Collin). It is indeed pushing scepticism to 



ROUND ULCER OF THE DUODENUM 319 

the limit to say, as does Collin in his otherwise admirable thesis, that 
the diagnosis of duodenal ulcer intra vitam is impossible. 

What I have just said will be illustrated by two positive, one 
probable, and one doubtful cases of duodenal ulcer. 

1. Secretary of Police R., of Berlin, comes from a healthy family, in which 
haemophilia has never been observed. No history of any previous illness. Took 
sick about twenty years ago (1876) with anaemia and tarry stools. Previous to 
that time there had been gastric and intestinal disorders. The patient sub- 
sequently recovered, and aside from temporary attacks of indigestion, was fairly 
well until 1891. At this time, after having suffered from a sense of oppression 
in the region of the stomach, he suddenly had several evacuations of very black 
stools. The patient fainted at the time. For several weeks he was under treat- 
ment at the Augusta Hospital. Following this there was a long period of good 
health, although from time to time there were attacks of pressure in the um- 
bilical region or in the pit of the stomach, and several small hemorrhages, to 
which little notice was paid by the patient. Another severe hemorrhage oc- 
curred in 1896, also with syncope. This, like the other, was recovered from. 
In 1897, while under treatment at Carlsbad, he had a return of the bleeding, 
which, however, did not last very long. From this time the patient never fully 
recovered his health. He has almost constantly a feeling of pressure and weight 
in the stomach and abdomen, not dependent upon the ingestion of food, and 
suffers from frequent eructations which are sour, but never putrefactive. In 
November, 1897, he had another severe hemorrhage. During the summer of 
1898 he took the "Wildungen cure for a catarrh of the bladder. In October, 
1898, had tarry stools to a moderate extent, and in December, 1898, a severe 
hemorrhage. These were always preceded by a sense of pressure, fulness in the 
abdomen, and eructations of gas. 

The patient does not remember ever having vomited or having had severe 
pains in the stomach or the intestines. The appetite has generally been good, 
but diminished after the attacks. 

Present condition (abstract) : Very anaemic— general nutrition much depre- 
ciated. Organs of circulation and respiration normal. Heart sounds clear, 
no adventitious sounds. Abdomen markedly relaxed ; the integument may be 
raised in folds. Under suitable illumination the stomach is appreciable ; it is 
apparently displaced downward, giving marked splashing sounds as far as three 
fingers' breadth below the umbilicus. The other abdominal conditions are nor- 
mal, and in particular there is no tenderness either in the region of the stomach 
or duodenum. Examination of the urine shows it to be normal. 

2. Oscar S., dealer in wood, Berlin, thirty-seven years old. The patient's 
mother was a chronic sufferer from gastric disorders, and was extremely emaci- 
ated when she died. His father is healthy. Since he was nine years old the 
patient has suffered from digestive troubles. At the beginning he used to have 
occasional pains in the gastric region, coming on without apparent cause and last- 
ing a quarter to half an hour. His appetite was good and the bowels regular. 
When he was almost thirty years old the pains increased, radiated toward the 
right side, especially toward the back and to the right shoulder blade, and 
became more frequent. They usually came on three to four hours after eating, 



320 DISEASES OF THE INTESTINES 

occasionally while fasting, and very often during the night. The sort of food 
ingested made no essential difference, for the pain appeared equally after either 
fluid or solid diet. Rest in the dorsal position alleviated the pains, while active 
exercise increased them. There was never any vomiting. Appetite and bowels 
were always in good condition. 

Under suitable diet, rest, and the use of Carlsbad water, sometimes at the 
Springs and sometimes in Berlin, his condition gradually improved. In Janu- 
ary, 1896, he again began to have severe pains of the character described 
above ; they extended backward and came on several hours after eating. He 
always felt well immediately after eating. This attack was followed by a 
slow improvement. In Januarj-, 1896, while travelling, he had a sudden 'pro- 
fuse hemorrhage from the intestine. The blood was at first diluted and mixed 
with faeces, but subsequently there was clear blood of coal-black colour. At 
the same time there was extreme prostration, so that the man, who was of her- 
culean build, was obliged to take to his bed and remain there for thirty-six 
hours. He was treated by rest in bed, and poultices, and later drank Carlsbad 
Miihlbrunnen. Improvement was rapid, and for a year and a half he was per- 
fectly well. In October, 1897, the pains returned in the right side several hours 
after eating, and were relieved by the ingestion of warm food. The treatment 
for ulcer, carried out for several weeks, was again followed by improvement. 
In the summer of 1898 he took the Carlsbad treatment with good results. 

The examination of the gastric contents on two occasions showed marked 
hyperacidity (HC1 0.28-1.25 per cent). Besides this, there was a characteristic 
tender point in the prolongation of the right parasternal line. At the last 
examination, November, 1898, the duodenal region was absolutely free from 
tenderness. 

3. Joseph L., bookkeeper, born in Poland, thirty-one years old. The 
family history has nothing of interest. At the age of sixteen the patient had 
typhoid fever, and at eighteen cholerine. . Since he was nineteen years old he 
has had gastric symptoms, which consisted in pressure in the pit of the stom- 
ach, frequent eructations, and marked constipation. For the past seven or 
eight years he has had hemorrhages from the intestines, as he says, every 
spring and fall. These are preceded by sudden extreme weakness, nausea, 
perspiration, and a desire to defecate. The first movement is free from blood, 
but those which follow are intimately mixed with blood of a coal-black colour. 
Has never vomited blood. During the past year there were four such hemor- 
rhages. In consequence of the frequent losses of blood the patient has become 
very anaemic, and has not recovered from them as he used to. 

From the notes taken when he was seen for the first time, only the follow- 
ing need be quoted : Palpation of the abdomen shows that on the right side 
above the umbilicus, about two fingers' breadth below the region of the gall 
bladder, there is a decidedly tender point, while the corresponding area on the 
left side is absolutely painless. The patient identifies this point as the seat 
of his pain, which is pressing in character, but never colicky. Aside from 
poikilocytosis, no changes are noted in the examination of the blood. 

It is perhaps worth recording that a few ova of the trichina spiralis were 
observed, but this probably has no bearing on the present illness. 

4. Mr. V., member of the Board of Accounts of Gross Lichterfelde, near Ber- 



ROUND ULCER OF THE DUODENUM 321 

lin, forty-one years old. Well until December, 1897. Since then, without any 
evident cause, he has had a sense of fulness a few hours after meals. An exam- 
ination which I made at that time gave absolutely negative results. On January 
6, 1898, he was suddenly taken with severe syncope and melaena. On January 
7th the syncope was repeated. On January 8th, after drinking milk, there was 
a slight vomiting of blood. Rectal feeding was resorted to. There was no 
further hemorrhage. Gradual return to health. Spent three months partly in 
the sanitarium and partly in the mountains. 

He still has occasional pains on the right side of the median line, usually a 
few hours after eating or after physical exertion. The painful area varies : 
it may be more to the right or toward the median line, and may even 
pass over to the left side. The pain is cut short by taking more food or 
alkalies. There are times when there is no pain. Appetite good, bowels 
confined. Examination shows that there is no sensitive area over the stomach, 
or to the right or the left of it, nor is there any dorsal tender point. 

The symptoms of the first and second cases fulfil all the require- 
ments for an exact diagnosis. The chronic course, the repeated 
attacks of hemorrhage per rectum, and the absence of any special 
dyspeptic symptoms, leave scarcely any doubt as to the nature of 
the trouble. The diagnosis of the other two cases is more difficult. 
In the third, the repeated attacks of melsena without any special 
gastric symptoms, and the sensitiveness on pressure to the right of 
the pylorus, make duodenal ulcer probable. Some of the other 
characteristic symptoms, such as occasional pain significantly local- 
ized, are absent, so that some doubt remains. 

The fourth case can not be decided offhand with any certainty, 
because the painful area is not fixed, the objective signs are absent, 
and there is heematemesis as well as melsena. The nature of the 
pain, coming on several hours after eating, might equally well be 
ascribed to hyperacidity. 

Differential Diagnosis 

It will be seen from the above histories, and still more so from 
the autopsy records of cases of this class, that the differential diag- 
nosis is often very difficult, especially when there is neither haema- 
temesis nor melsena. In such cases many physicians prefer not to 
commit themselves to a diagnosis or to attempt a differential diag- 
nosis. I think this is going too far. If we were to wait for the 
appearance of hemorrhage in gastric ulcer, at least 30 per cent of all 
the cases would remain undiagnosticated, and therefore uncured. 

In my opinion the greatest difficulty lies in distinguishing ulcer 
of the duodenum from gastric hyperacidity. Yery often both dis- 



322 DISEASES OF THE INTESTINES 

eases give the same symptoms : pain several hours after eating, 
relieved by the ingestion of food or alkalies, and localized at the 
pylorus or in the duodenum. The pylorus and duodenal region 
may be more or less sensitive to pressure in hyperacidity. I think 
that when the latter cases do not improve upon a diet suitable to 
that condition, it would be well to begin treatment as for ulcer as 
soon as possible. I have done so several times, with the result that 
from that time on the patients were free from their discomforts. 
Just as in gastric ulcer, von Leube's treatment has a certain value 
for the differential diagnosis of doubtful cases, so, in long-estab- 
lished cases of hyperacidity with symptoms suggestive of ulcer of 
the duodenum I would recommend that the treatment for the latter 
condition should be instituted experimentally. 

As in gastric ulcer, the differential diagnosis between duode- 
nal ulcer and irregular cholelithiasis, with or without icterus or 
cholangitis, may be exceedingly difficult. Icterus as well as intes- 
tinal hemorrhage are not uncommon in cholelithiasis. In his Clin- 
ical Study of Cholelithiasis (p. 130 et seq.), to which we refer the 
reader for further information, Naunyn has described the various 
conditions in which the latter affection may be associated with intes- 
tinal hemorrhage. From a differential diagnostic standpoint the 
following must be noted : enlargement, tenderness, and tumefac- 
tion of the liver, the presence of a decided sensitiveness on pressure 
over the posterior surface of the liver (in the neighbourhood of the 
twelfth dorsal vertebra), and sometimes an intermittent pyrexia. In 
complicated cases it is difficult to avoid mistakes. 

If the pains are atypical with frequent remissions and exacerba- 
tions, a correct diagnosis is merely a matter of accident. As an 
illustration of this I will give one of the numerous mistaken diag- 
noses which appear in clinical records — that published by Had- 
ham 23 . A painter suffered from severe colicky pains with free 
vomiting, which, as his gums showed the lead line, were taken to 
indicate lead colic. Autopsy revealed an ulcer with sharp cut mar- 
gins on the anterior wall of the duodenum. Two similar obser- 
vations have recently been reported by Alvazzi-Delfrate 24 . 

When there are intestinal hemorrhages, the chances for a cor- 
rect diagnosis are more favourable. The hemorrhage in itself is, 
however, not pathognomonic. The diagnosis can only be safely 
made when all the clinical symptoms are present, but even then 
it is often exceedingly difficult to distinguish duodenal from gas- 
tric ulcer. If we arrange the differential features in the order 



ROUND ULCER OF THE DUODENUM 323 

of their value, age and sex must be given first importance. Ulcer 
of the duodenum occurs with preponderating frequency during 
the third and fourth decades, ulcer of the stomach during the 
developmental age ; ulcer of the duodenum is vastly more frequent 
in men than in women. In duodenal ulcer there is an absence of 
special gastric symptoms, such as anorexia and vomiting ; ingestion 
of food does not increase the pain, but diminishes it if present ; 
the pain is localized and does not radiate ; hemorrhage per os when 
present at all, is scanty in comparison with the melsena ; the hemor- 
rhages are repeated extremely often, while in gastric ulcer they are 
not so common. 

Although the treatment of both kinds of ulcers and the thera- 
peutic results obtained are the same, an attempt should be made to 
distinguish between the two conditions, if possible, for, aside from 
the danger of perforation, the prognosis of duodenal ulcer is 
much more favourable than that of gastric ulcer, since the tend- 
ency to stenosis or carcinomatous formation (see p. 293) is mark- 
edly less. 

Complications 

Duodenal ulcer is noted for the remarkable number of its com- 
plications. Either because of their frequency or on account of 
the peculiar symptoms to which they give rise, some of these are of 
practical importance. The most important is : 

1. Perforative Peritonitis. — In Collin's collection of 262 cases 
this was observed 181 times, or 69 per cent. The seat of the perfo- 
ration — and this is of especial importance to the surgeon — like 
that of gastric ulcer, is usually on the anterior wall. The rupture 
may occur into the abdominal cavity and thus cause death by per- 
forative peritonitis,* or else neighbouring organs — the liver, the 
pancreas, the gall bladder, or colon — may be encroached upon. In 
this way permanent adhesions or fistulous openings into the gall 
bladder or the colon are formed, or there may be an erosion of 
an important artery or vein and death from hemorrhage, or a sub- 
phrenic abscess with pyopneumothorax, may result. 

Furthermore, a duodenal ulcer on the anterior or posterior wall 
may cause an abscess, and ultimately, by perforation of the abdomi- 
nal wall, result in a duodenal fistula ; or the ulcer may rupture 

* As has been shown by a case reported by Bardeleben (Virchow's Archiv, 
vol. v, p. 2), the perforation need not always cause peritonitis. The fatal result 
may come about just as rapidly from shock, collapse, or hemorrhage. 



324 DISEASES OF THE INTESTINES 

into a cavity walled off by previous adhesions, which increase until 
the abscess is so encapsulated as to produce a plastic resisting mass. 
I have seen a case which I believe to have been of this sort. 

All these possibilities are founded upon more or less numerous 
clinical observations described in the above-mentioned monographs 
on duodenal ulcer. Since it would take too long to describe each 
of them, the reader is referred to these authors for details. There 
are no specific symptoms which indicate the site of the perfo- 
ration. The answer is most decidedly in the negative. There 
are accounts of operations (Bryant 25 , Brissaud 26 , Sheild 9 , Lock- 
wood 27 , Lennander 28 ) undertaken for supposed perforating appen- 
dicitis, in which the autopsies showed that the cause lay in a 
duodenal ulcer that had perforated. The error was usually due to 
the fact that the chief painful point was located in the ileo-caecal 
region. It is hardly necessary to call special attention to the cir- 
cumstance that a diagnosis of perforation is open to all the mistakes 
that may be made in the diagnosis of perforation of an ulcer in 
any other part of the intestine (strangulation, etc.). 

2. Icterus. — Icterus is occasionally observed as a complication 
of duodenal ulcer, although Collin could collect only 9 cases in 
which it occurred. It begins as a true duodenitis, which involves 
the papilla of Yater. Cases of this kind have been seen by so 
competent an observer as Henoch, so that there is no good rea- 
son for doubting them. The jaundice has the well-known char- 
acter of the catarrhal form, except that it is transient and does 
not cause enlargement of the liver. In a case reported by Krauss, 
the cause of the icterus was inflammatory adhesion of the duode- 
num to the gall bladder. Another form, more easily accounted 
for by what will shortly be described, occurs when the ulcer is located 
in the descending portion of the duodenum. 

On account of its infrequency, icterus is of scarcely any impor- 
tance for diagnostic or differential diagnostic purposes. Except 
under some favourable circumstances, it rarely throws any light 
upon the clinical picture. 

3. Formation of Stenoses oy Cicatrization of the Ulcer. — In a 
small number of cases the cicatrization of a duodenal ulcer leads to 
stenosis and consecutive dilatation of the parts lying above it — that 
is, of the stomach, or the corresponding portion of the duodenum. 
As the ulcer is most frequently in that part of the duodenum adja- 
cent to the stomach, it is in the latter organ that ectasia is most 
often met with ; according to Collin, 18 times in 262 cases. Duo- 



ROUND ULCER OF THE DUODENUM 325 

denal dilatation was observed only 4 times. The symptoms of this 
condition will be considered in the chapter on Intestinal Stenosis. 
Lastly, in rare cases, when the ulcer is located in the neighbour- 
hood of the ampulla of Yater, obliteration of the common bile 
duct and permanent jaundice may follow. This complication will 
make the diagnosis and the treatment very difficult. 

4. Carcinomatous Ulcer of the Duodenum. — Carcinomatous de- 
generation of the ulcer seems to be rare. Altogether, but 4 cases 
have been observed (Eichhorst 28 , Ewald 29 , Mackenzie 30 , Schrotter 31 ). 
Unless it be that many cases are overlooked, this would constitute a 
striking variance from the frequency of carcinomatous ulcer of the 
stomach. 

Treatment 

The treatment of ulcer of the duodenum differs only in a few 
points from that of ulcer of the stomach. For the details of the 
latter I would refer to my Diagnosis and Treatment of Diseases of 
the Stomach, Part II, third edition, page 55, and will limit what 
follows to a brief sketch of the plan of treatment. 

If hemorrhage set in, absolute rest in bed is the first require- 
ment. The stomach should be put at rest, and for several days ali- 
mentation carried on by the rectum. Following this, the most prom- 
ising course is von Leube's rest-cure treatment for ten to fourteen 
days, with the application of warm poultices, and a milk diet. After 
the cessation of the pain the diet may be cautiously increased week 
by week. Alkalies or Carlsbad water, bismuth or nitrate of silver, 
may be useful as adjuvants. In very obstinate cases it is advisable 
to give the stomach a rest by exclusive rectal feeding, under careful 
supervision, for a week or a fortnight. Opiates can not be dis- 
pensed with when the pain is severe. Long-continued physical 
rest, careful diet, and the avoidance of alcohol and tobacco are to be 
insisted upon. 

When a cure is not obtained by palliative measures, and life 
is threatened by continuous pain or profuse hemorrhages, when 
there are symptoms of cicatricial stenoses not relieved by lavage, 
or when there is perforative peritonitis or subphrenic abscess, sur- 
gical procedures may be indicated. Owing to the analogy which 
these indications bear to those that arise in ulcer of the stomach, 
we refer the reader to the latest work of Mikulicz 32 . 

Up to the present time experience in the surgery of duodenal 
ulcer has been scanty. In one case Codivilla 33 excised the ulcer 

22 



326 DISEASES OF THE INTESTINES 

by a gastro-enterotomy with good result. Lange 34 performed a 
plastic operation on the pylorus in a case of cicatricial stenosis from 
duodenal ulcer, with equally good result. 

Operations for perforative peritonitis have been successfully 
performed in several quarters (Herczl 35 , Landerer and Gliicks- 
mann 36 , Wannach 37 ). In three cases reported by Lennander 38 a 
fatal termination occurred in spite of the operation. 

In view of the absolutely hopeless prognosis of ulcer of the 
duodenum after perforation, surgical intervention should be un- 
dertaken as soon as possible — within ten to twelve hours at least 
after the diagnosis is assured and the primary shock has been recov- 
ered from. 

Subphrenic pyopneumothorax or other abscess formations, are 
treated according to the prevailing surgical methods. 

LITERATURE 

1. J. Krauss. Das perforirende Geschwiir im Duodenum, Berlin, 1865. 

2. Chvostek. Medicinische Jahrbucher, Wien, 1883, Heft 1, S. 1-58. 

3. Boucquoy. Archives generates de medecine, 1887. 

4. Oppenheimer. Das Ulcus pepticum duodenale. Inaug. -Dissert. , Wiirz- 

burg, 1891. 

5. Reckmann. Ueber Ulcus duodenale u. seine Diagnose. Inaug-Dissert., 

Berlin, 1893. 

6. Collin. Etude sur l'ulcere simple du duodenum. These de Paris, 1894. 

7. Dickenson. Royal Med. and Chirurg. Society, January 9, 1894. 

8. Perry and Shaw. Guy's Hosp. Rep., p. 171, 1894. 

9. Marmaduke Sheild. Internat. Med. Magazine, vol. iii, No. 12, 1895. 

10. Schulze. Beitrage z. Kenntniss des perforirenden Duodenalgeschwurs. 

Inaug. -Dissert., Greifswald, 1873. 

11. Brambillo. Cited from Virchow-HirscrTs Jahresber., 1882, Bd. ii, S. 168. 

12. Pauly. Aerztliche Sachverstandigen Zeitung, 1897. 

13. L. Landau. Ueber Melana. der Neugeborenen u. Bemerkungen liber d. 

Obliteration d. fotalen Wege. Breslau, 1874. 

14. v. Mering. Verhandl. d. Congresses f. innere Medicin, 1893. 

15. Moritz. Verhandl. d. 65 Versammlung d. Gesellsch. deutscher Natur- 

forsche u. Aerzte in Nurnberg, 1893. 

16. Burwinkel. Deutsche med. Wochenschr., 1898, No. 52. 

17. Albers. Die Darmgeschwilre, 1831. 

18. Mayer. Die Krankheiten des Zwolffingerdarmes, Diisseldorf, 1844. 

19. Starke. Deutsche Klinik, 1870. 

20. v. Leube. Specielle Diagnose, 2te Aufl., S. 274. 

21. A. Robin. Cited from Collin (reference No. 6). 

22. Devic and Roux. Province medicale, 44-47, 1895. 

23. Hadham. The Lancet, February 18, 1871. 



ROUND ULCER OF THE DUODENUM 327 

24. Alvazzi-D elf rate. Gaz. med. di Torino, 1897, No. 7. Cited from Cen- 

tralbl. f. innere Medicin, 1897, S. 845. 

25. Bryant. Semaine m^dicale, 1893, p. 335. Cited from Collin (reference 

No. 6). 

26. Lockwood. Transact. Med. Soc, vol. xv, p. 91, 1895. Cited from review 

in Centralbl. f. Chirurgie, 1895, No. 26. 

27. Lennander. Ueber Appendicitis, 1895, S. 29. 

28. Eichhorst. Schmidt's Jahrbiicher, Bd. ccxx, S. 23. 

29. C. A. Ewald. Berliner klin. Wochenschr., 1886, No. 32. 

30. Mackenzie. St. Thomas Hosp. Rep., vol. xx, p. 341, 1892. 

31. Schrotter. Aerztliche Bericht des k. k. Allgem. Krankenhauses zu Wien, 

1887, S. 27. 

32. Mikulicz. Mittheilungen a. d. Grenzgeb. d. Medicin u. Chirurgie, 1897, 

Bd. ii. 

33. Codivilla. Sperimentale, Mem. orig., vol. xlvii, pp. 4 and 6. Cited from 

Landerer u. Gliicksmann (reference No. 36). 

34. Lange. Annals of Surgery, vol. xxxvi, p. 2, 1893. 

35. Herczl. Orvosi Hetilap, 1895, No. 50. Cited from Arch. f. Verdau- 

ungskr., Bd. ii, S. 251. 

36. Landerer u. Gliicksmann. Mittheilungen a. d. Grenzgeb. d. Med. u. 

Chirurgie, 1896, Bd. i, S. 168. 

37. Wannach. Arch. f. klin. Chirurgie, 1898, Bd. lvi, Heft 2. 

38. Lennander. Mittheilungen a. d. Grenzgeb. d. Med. u. Chirurgie, 1898, 

Bd. iv, Heft 1, S. 91. 



CHAPTEE XVIII 

INTESTINAL NEOPLASMS 
A. MALIGNANT NEOPLASMS OF THE INTESTINES 

I. Carcinoma 

Preliminary Remarks. — Malignant tumours of the intestines 
are so very frequently carcinomatous that, in discussions relating to 
malignant new growths, cancer is almost exclusively the tumour in 
question. The other malignant tumours (sarcoma, lymphosarcoma), 
however, will require brief consideration because of the well-marked 
clinical pictures they occasionally present. 

Eegarding the absolute and relative frequency of intestinal car- 
cinoma, there are many extensive and instructive statistics. 

A. Zemann 1 found, in 21,624 autopsies performed at the Yienna 
General Hospital, 2,070 neoplasms directly causing death, of which 
number 1,744 were cancers — i. e., 84 per cent of all neoplasms. 

Of these 1,744 cancer cases, 912 (52 per cent) were tumours of 
the gastro-intestinal canal, the " canal " in this sense beginning at 
the tongue and including the anal orifice. 

The various portions of the gastro-intestinal tract were affected 
in the following proportion : 

Tongue 37 

Pharynx 34 

(Esophagus 136 

Stomach 540* 

Duodenum 3 

Ileum 6 

Caecum 12 

Vermiform appendix 1 \ 165 

Colon 32 

Sigmoid flexure 30 

Rectum 81 

* I. e., 2.5 per cent of all the autopsies. 
328 



INTESTINAL NEOPLASMS 329 

In his excellent work on the intestines, Nothnagel tabulates like 
statistics derived from a study of similar material. George Hei- 
mann 2 has recently published extensive tables which are very useful 
in the study of the pathology of the alimentary canal. During the 
years 1895 and 1896, 20,054 patients died of cancer in the gen- 
eral hospitals of Prussia, of whom 10,537 were cases of cancer of 
the gastro-intestinal tract. The different portions of the canal were 
affected as follows : 

Tongue 269 

Pharyngeal and buccal mucous membrane . . 192 

(Esophagus 1,011 

Stomach 4,288 

Intestinal canal in toto 1,706 

Of these, the rectum 1,204 

Liver and gall bladder 979 

Pancreas 92 



Of the cases of cancer of the intestines (exclusive of the rectum), 
20 involved the small intestine and 224 the large intestine ; 49 of 
the latter affected the sigmoid flexure ; in 258 cases the portion af- 
fected was not mentioned. 

These statistics (which in the main agree with others) demon- 
strate the relative infrequency of intestinal cancer as compared 
with cancer of the stomach. The striking disparity in numbers 
between cancer of the small and that of the large intestine, and 
the overwhelming frequency of rectal cancer, are noteworthy. 
Finally, these statistics prove the frequency of cancer of the sig- 
moid flexure. Next in frequency to these are the carcinomata of 
the colon (especially at the flexures), and last of all those of the 
caecum. 

Regarding sex, authorities differ. Some believe that females 
are of tener affected (Berard 3 , Rokitansky 3 , P. Riipp 4 ) while others 
regard intestinal cancer as more frequent in males (Maydl 5 , Gr. 
Heimann 2 ). It is certain, however, that cancer of the rectum occurs 
more frequently in men. 

The age of the patient is an important consideration. Most cases 
occur between the fourth and sixth decades. As Maydl 5 , Nothnagel, 
and G. Heimann 2 correctly pointed out, intestinal cancer quite fre- 
quently occurs in even the earlier periods of life ; particularly is this 
true of cancer of the rectum, many cases of which have been ob- 
served in young people. In partial contrast to the above, sarcoma and 



330 DISEASES OP THE INTESTINES 

lymphosarcoma occur usually during the first to the fourth decades, 
and only very infrequently in the fifth and sixth. Regarding fre- 
quency, sarcoma, in contrast to carcinoma, is oftener situated in the 
small intestine than in the large. (Compare chapter on Sarcoma.) 

It will hardly be necessary to discuss at length the etiology of 
cancer and sarcoma, since, with the exception of the bacterial and 
protozoan theories, nothing of importance has been brought to light. 
On the other hand, histological investigations by modern investi- 
gators, particularly Virchow, Thiersch, Waldeyer, Hauser,* Kib- 
bert, Hansemann, Lubarsch, and others, have proved more fruit- 
ful. A full description of these as yet incomplete investigations 
would lead too far, hence we will mention only a few pertinent 
facts. In the great majority of cases intestinal cancer is a primary 
affection, very rarely metastatic. The most frequent form is cylin- 
drical epithelial. It originates, as do all other forms of intestinal 
cancer, from the cylindrical epithelial cells, and shows most often a 
glandular type (hence " carcinoma adenomatosum cylindro-epitheli- 
ale," Hauser, loc. cit.). The second most frequent form is the 
medullary (carcinoma medullare), which shows a decided tendency 
to break down and form ulcerations (intestinal hemorrhages). Some- 
what less frequent (most often in the rectum) is colloid carcinoma. 
In striking contrast to the stomach, true scirrhous cancer occurs 
very rarely in the intestine, in most cases in the rectum. 

The histological construction of the different types is not with- 
out its clinical significance. The soft, medullary type of cancer 
generally forms a diffuse tumour, while the scirrhous is a different 
growth, infiltrating the intestinal walls and being occasionally quite 
circumscribed. There are, however, exceptions to both these forms. 

In its early stages cancer of the large intestine produces but 
slight changes in the mucous membrane ; only later does the growth 
show its special characteristics — propagation and tendency to ulcera- 
tion. Another characteristic is its growth in a circular, girdlelike 
fashion. Isolated nodules (at times of large size), or long, diffuse 
infiltration, rarely occur. 

From the two above-mentioned characteristics (viz., tendency 
to ulceration and circular growth of the tumour) we have the 
following two clinical conditions : A tendency to hemorrhage to 



* Compare Hauser's interesting and critical description of the different theories 
of cancer in Das Cylinderepithel Carcinom des Magens und Dickdarms, Jena, 
1890, p. 109. 



INTESTINAL NEOPLASMS 331 

purulent disintegration, even to separation of portions of the tumour 
and the development of stenoses. These symptoms will later be 
discussed at length. 

Because of this tendency to ulcerate, superficial layers of the 
bowel may be involved in this destructive process, and perfora- 
tion may occur. The development of a stenosis, which may at 
times cause complete obstruction, produces dilatation and muscu- 
lar hypertrophy of that portion of the intestine above the stricture. 
Through overaction in this dilated and hypertrophied portion nor- 
mal propulsion of contents is maintained, until a disproportion 
between the power of the hypertrophied wall and the resistance 
offered occurs, and an intestinal paralysis (ileus paralyticus), or, 
from extreme overexertion of the hypertrophied part, a rupture 
of the intestine at its weakest point results. 

The peculiar characteristic of cancer to form metastases by way 
of the blood and lymph channels is also present in intestinal car- 
cinoma. 

The mesentery is supplied with lymphatics which lead to the 
mesenteric glands, and hence the latter are the first to become 
diseased, further metastatic involvement depending upon the site 
of the tumour. Thus, according to Riipp 3 , the lumbar glands are 
involved in cancer of the sigmoid flexure of the colon ; the omental, 
and later the prevertebral glands, in cancer of the transverse colon. 

Metastatic carcinoma of the lymph nodes may cause secondary 
intestinal obstruction, a condition which I have twice observed in 
cancer of the uterus. Disseminated carcinosis of the peritoneum is 
relatively frequent. 

The observations of Maydl 5 and Hausmann 7 , confirmed by 
Riipp 3 , are of extreme surgical interest. They assert that metas- 
tases are observed only late in intestinal carcinoma ; this is partic- 
ularly true of cancer of the rectum. Iverson 8 cites 47 autop- 
sies of rectal carcinoma, of which 21 were free from secondary 
involvement of glandular organs; Kraske 9 , in 12 cases, found 
metastases in only 6. 

According to Hauser (loc. cit.), there is a connection between the 
type of carcinoma and location and variety of the metastatic for- 
mations. Thus colloid carcinoma very rarely causes secondary 
involvement of internal organs (e. g., the liver), but frequently 
secondarily involves the serosa, lymph glands, and bones. Large 
medullary carcinoma produces metastases principally in the re- 
gional lymph glands, while the small scirrhus may cause a large 



332 DISEASES OF THE INTESTINES 

metastatic deposit in the liver. Besides the lymph channels, cancer 
may also spread by way of the blood-vessels. Tumour masses may 
erode the vascular wall (particularly of the veins), and thus infec- 
tious material enters the blood stream. Since its tributaries are 
directly in the intestines and are often connected with the ma- 
lignant growth, the portal vein is especially prone to carry infec- 
tion. For this reason the liver- is often secondarily involved, while 
metastatic deposits in the lungs, uterus, and ovaries are rarer. 

The tumour frequently becomes adherent to the neighbouring 
organs. Such adhesions may lead to complications, but they are 
favourable in so far as they prevent perforation. The most fre- 
quent complications of this kind are adhesions to and fistulous com- 
munication with the stomach, bladder, other portions of the intes- 
tines, the abdominal wall, genitals, etc. 

General Symptomatology and Diagnosis of Intestinal 
Carcinoma 

The symptoms of intestinal cancer vary so much according to 
its location that it seems judicious to consider separately cancer of 
the small intestines, the colon, and the rectum. A description of 
sarcomatous and lymphosarcomatous diseases of the intestines will 
be found in another chapter. 

All cancers have certain general characteristics, which, although 
of no special significance individually, collectively complete the 
clinical picture of the disease. These are the history, the deport- 
ment of the body weight, the condition of the urine and blood, the 
occurrence of oedema of the ankles or of ascites, and, finally, the 
presence of infiltrated lymph glands. 

1. Hereditary disposition to carcinoma is perhaps of value. 
Many striking examples of such a tendency have been described 
(e. g., family of Napoleon I). Traumatisms received during recent 
years should be noted in the history. 

2. In obscure or atypical cases of intestinal cancer the body 
weight is of great importance, but is frequently not sufficiently 
considered. My experience has taught me that patients weigh 
themselves only when there has already been quite an apparent 
loss of weight, perhaps even as much as 10 to 20 pounds. At this 
stage, too, there is beginning cachexia. By weighing the patient 
at regular intervals the physician may often note the degenera- 
tive character of the disease much earlier. If the appetite be 
good and the condition of the upper portion of the alimentary 



INTESTINAL NEOPLASMS 333 

canal normal, forced feeding may be tried ; if the patient then 
lose in weight there is probably some obscure malignant disease 
of the intestine, usually a neoplasm present. The progressive loss 
in weight should neither be over- nor underestimated, but re- 
garded as a warning to examine the patient with greater care and 
frequency in order to recognise the obscure condition as early as 
possible. It must be remembered, however, that increase in weight 
does not by any means exclude carcinoma. 

3. The examination of the urine, particularly the finding of 
indican and of Eosenbach's colouring matter may aid in making a 
diagnosis. The diagnostic significance of these bodies has already 
been dwelt upon (see page 132). Kast and Baas 10 attribute special 
value to the presence of ethereal sulphuric acids in the urine as a 
sign of intestinal putrefaction. This has occasionally been impor- 
tant to surgeons in determining whether a stenotic obstruction was 
successfully removed by o}3eration or not. Eommelare n and others 
drew attention to a lessened excretion of nitrogen by the urine in 
carcinoma, but the investigations of F. Muller 12 and G. Kleru- 
perer 13 have shown this conclusion to be deceptive. 

4. Examination of the blood in cancer is of little diagnostic 
value. There is a diminution in percentage of haemoglobin, accom- 
panied by a corresponding decrease in the number of red blood-cells, 
and of the specific gravity of the blood. ''Digestion leucocytosis." 
recently claimed by Schneyer 14 as diagnostic for cancer of the 
stomach, has been disproved by later investigations. As yet we 
have no reports regarding its occurrence in intestinal cancer. 

F. Henry 15 has lately called attention to the differentiation between 
cancer of the stomach and pernicious ansemia by means of a count 
of the blood-cells. He has pointed out that in cancer the number 
of erythrocytes is never less than 1,500,000 per cubic millimetre, 
while in pernicious anaemia it is almost invariably below 1.000,000. 

5. The early occurrence and disappearance of oedema of the 
a/iMes might, with a certain amount of reserve, be accepted as a 
contributory sign to the diagnosis of a malignant disease. I can not 
recall ever having seen it in any of my cases of intestinal cancer, 
and can find no mention of it elsewhere in the literature of the sub- 
ject (cf. Intestinal Sarcoma, p. 332). Ascites is, of course, one of 
the most frequent accompanying symptoms of advanced cancer of 
the intestines. Once, during an operation for cancer of the csecum, 
I observed slight ascites, which, because of its small quantity, it 
had been impossible to diagnosticate before operation. 



334 DISEASES OF THE INTESTINES 

6. Markedly enlarged inguinal or supraclavicular glands may 
lend support to the diagnosis. Swelling of the latter group is 
very rare, while enlargement of the inguinal glands, though fre- 
quent, occurs under most varied conditions. At all events, exci- 
sion and histological examination may aid the diagnosis. 

(a) CANCER OF THE SMALL INTESTINE 

For the clinical diagnosis of cancer of the small intestine it is 
best to distinguish between cancer of the duodenum and that of 
the jejunum and ileum. 

1. Cancer of the Duodenum 

According to their relation to the papilla of Yater, these tumours 
of the duodenum are conveniently subdivided into suprapapillary, 
infrapapillary, and circumpapillary. 

(a) Suprapapillary Caxcer 

The symptoms of suprapapillary cancer are not well denned, and 
it is exceptional to arrive at even a probable diagnosis. Of some 
value are the subjective symptoms produced by the marked disturb- 
ance of gastric motility : the f eeling of the tension and pressure or 
pain in the epigastric region, eructations, nausea and vomiting, loss 
of appetite, constipation, oliguria, marked thirst, and a decided 
feeling of illness and increased debility, sometimes sufficient to 
confine the patient to bed. 

Of the objective symptoms, the earliest is the presence of a 
tumour. This lies in the right hypochondrium, is hard and 
uneven, painful on pressure, and is entirely immovable or only 
slightly movable. 

The second objective symptom is the presence of a supraduode- 
nal dilatation, which naturally leads to enlargement of the stomach. 
Here it will not be sufficient to diagnosticate simply anatomical 
dilatation of the stomach, but by repeated examinations of the 
stomach contents we must seek for proof of stagnation. As a re- 
cently published case of Czygan 16 has shown, the examination of 
the stomach contents for the presence or absence of hydrochloric 
acid, for lactic and other organic acids, for sarcinse and yeast, 
lactic-acid bacilli, ferments, etc., may be of aid to the diag- 
nosis. In the above-mentioned case, besides a tumour in the right 
hypochondrium and all other symptoms of cancer, there was 
found (except a few days before death) normal hydrochloric-acid 



INTESTINAL NEOPLASMS 335 

secretion in the dilated stomach. I found the same chemical con- 
ditions in a case which I had under observation, and which, because 
of the absence of tumour, was diagnosticated as a benign pyloric 
stenosis. Laparotomy disclosed a tumour of the first portion of the 
duodenum as the cause of the stenosis. 

We must, however, not lay too much stress upon the results 
of chemical examinations, since hydrochloric acid is often present 
for a long time in carcinoma of the pylorus, and, owing to the 
stagnation which results from proximity to the stomach, may be 
absent and lactic present in duodenal cancer. 

Czygan 16 mentions another point of possible diagnostic value : 
the presence of splashing sounds, particularly between the tumour 
and the free border of the ribs. Upon emptying the stomach 
these sounds disappeared, but, upon filling the organ, were again 
observed, especially in the region above mentioned. 

If an immovable or slightly movable tumour be felt in the right 
hypochondrium, by careful consideration of the above criteria we 
may venture upon the probable diagnosis of duodenal cancer, or, at 
any rate, arrive at the differentia] diagnosis between this disease 
and cancer of the pylorus. When no tumour is palpable, one can 
diagnosticate the gastrectasis, and, under favourable circumstances, 
the pyloric stenosis also. 

08) Infrapapillary Carcinoma 

Subjectively, infrapapillary carcinoma differs but little from 
the above-described suprapapillary type, excepting in one very 
marked symptom, viz., the vomiting of bile. When this occurs 
constantly it should arouse suspicion of an infrapapillary ste- 
nosis. 

Objectively. — We again have an immovable tumour situated 
in the right hypochondrium, more or less distant from the free 
margin of the ribs, and painful on pressure. In addition there 
is the bilious vomiting, from which Leichtenstern 17 was the first 
to establish the diagnosis of carcinoma of the descending portion 
of the duodenum.* Examination of the gastric contents will fre- 
quently show the permanent presence of bile even before vomiting 
occurs. 

As a result of the stagnation of contents, dilatation of the 
stomach may gradually be established, but because of frequent 

* According to A. Pic, Chomel is said to have recognised and interpreted, as 
early as 1852, continued bilious vomiting. 



336 DISEASES OF THE INTESTINES 

vomiting, mild stenosis, and early lavage of the stomach may be 
overlooked. 

At present it is impossible to state whether the examination of 
the gastric contents is of diagnostic or only contributory value. 
In an exhaustive study of a case, Herz 18 constantly found lactic acid 
present and hydrochloric absent in the strongly bilious stomach con- 
tents. The diagnosis of carcinoma of the stomach was made, but the 
constant presence of biliary matter might have attracted attention 
to the real seat of the lesion. Moreover, a tumour was not palpable. 
The presence of the tumour will not always verify a probable 
diagnosis. Thus, for example, Gerhardi 19 , Hagenbach 20 , Wilms 21 , 
and others have shown that it is absolutely impossible at times 
to differentiate between infrapapillary carcinoma and tumours of 
the head of the pancreas. Diseases of the gall bladder — e. g., 
adhesions to the duodenum, compression by retroperitoneal glandu- 
lar tumours, cicatricial strands following peritonitis, etc. — are con- 
ditions too complicated for differentiation.* 

In isolated cases the history and clinical course of the disease 
are of some assistance. Previous melsena or haematemesis, signs of 
cholelithiasis or of an old duodenal ulcer, glycosuria, or fatty stools, 
may favour the one or the other diagnosis. Weecke 22 has pointed 
out that irritations or ulcerations of the walls of the common bile 
duct by gallstones may produce duodenal cancer, particularly the 
form next considered. 

In the absence of tumour the diagnosis becomes quite uncer- 
tain. In such cases the age of the patient, emaciation, cedemse, or 
ascites may point to the correct diagnosis, although the absence 
of severe general symptoms and the slow development of the dis- 
ease may lead to a more optimistic conclusion. Such favourable 
conditions are, however, rare. 

7. ClRCUMPAPILLARY CARCINOMA 

In this the neoplasm develops in the neighbourhood of the 
papilla of Yater and compresses the bile duct. Whether in these 
cases we have to do with primary carcinoma of the papilla, or, 
as Pic 23 contends, with cancer of the pancreas, is certainly of scien- 
tific interest ; from a clinical (particularly a diagnostic) standpoint 

* A case from Kussinaul's clinic, described by Calm in 1886, was diagnosticated 
as duodenal cancer on account of the presence of a palpable tumour and continu- 
ous biliary vomiting. The autopsy showed a retroperitoneal lymphosarcoma com- 
pressing the descending portion of the duodenum. 



INTESTINAL NEOPLASMS 337 

this distinction is almost valueless. As discussion on this point is 
foreign to the subject at issue, it will not be further considered, 
and we shall at once proceed to the symptomatology of papillary 
carcinoma. 

Subjective /Symptoms. — These are of secondary importance, viz., 
pain in the region of the stomach or liver, noncharacteristic but 
not biliary vomiting, constipation or diarrhoea, loss of appetite, and 
progressive loss of strength. One or all of these symptoms may be 
present, but they are of less value than the objective symptoms. 

Objective Symptoms. — The main and most apparent symptom is 
icterus. Bard and Pic u have shown, however, that icterus may be 
entirely absent, and maintain that when a tumour and icterus are 
present the carcinoma generally has its origin in the pancreas. On 
the other hand, Lannois and Courmont 25 have published several 
cases of undoubted ampullary cancer with icterus. I myself have 
made two similar observations. According to my experience, the 
manner of development of the icterus is extremely important. As 
in catarrhal icterus, this is sudden, and usually without pain, but 
as Janicke has shown, severe attacks similar to gallstone colic may 
exceptionally occur, obscuring the true clinical picture. The diffi- 
culty of diagnosis is also illustrated by a case which I observed 
of cholelithiasis with a large gallstone in the common bile duct. 
The stone was passed without any pain, and the whole condition 
was accompanied only by chronic icterus. Unless sudden inter- 
current complications — e. g., marked cachexia, hsematemesis, me- 
lsena, and irregular fever — indicate the correct diagnosis, it will be 
impossible, therefore, in the first few days or weeks of the disease, 
to make a differential diagnosis between simple icterus, cholelithia- 
sis, and beginning carcinoma 

The longer icterus continues, the more resistant is it to the 
usual methods of treatment, and the sooner the general condition of 
the patient suffers, the more probable will the diagnosis of a malig- 
nant neoplasm become, particularly when the above-mentioned symp- 
toms occur in middle-aged patients. In two cases of absolute ano- 
rexia under my observation, the total absence of response to cus- 
tomary therapeutic measures aided the diagnosis, because such ex- 
treme obstinacy is not found in either duodenal icterus or chole- 
lithiasis. "We also meet with this extreme anorexia in hypertrophic 
cirrhosis of the liver (which is otherwise sufficiently distinguished 
from circumpapillary carcinoma), and especially in pancreatic carci- 
noma, soon to be described. To my knowledge, no examination of 



338 DISEASES OF THE INTESTINES 

the stomach contents in cases of circurupapillary carcinoma have 
been published. In one of my cases, despite absolute anorexia, 
there was no disturbance in the chemical or the motor functions 
of the stomach. 

In circumpapillary carcinoma the liver is usually not enlarged, 
and the gall bladder is decreased in size. A tumour is rarely 
palpable, but when present it is too deeply situated to be distinctly 
outlined. Naturally, as in the case described by Kernig ^ the pres- 
ence of a tumour is of great aid to the diagnosis ; it may, however, 
be misleading, for it may simulate primary cancer of the gall blad- 
der or liver. If icterus be absent, even in the presence of a 
tumour the diagnosis will be extremely difficult. It may be 
very difficult to differentiate between carcinoma of the papilla 
and of the pancreas. Bard and Pic 24 have recently published 
a set of symptoms which, recognised sufficiently early, is said to 
render the diagnosis of cancer of the pancreas as easy as that 
of cancer of the stomach. The symptoms are well-marked, 
constantly increasing icterus, with enormous dilatation of the 
gall bladder, rapid emaciation and cachexia, usually accompanied 
by subnormal temperature and absence of appreciable enlarge- 
ment of the liver. For excellent reasons, in which I fully 
concur, Oser 28 has belittled the significance of this clinical syn- 
drome. 

Only the presence of sugar in the urine (according to Mi- 
rallie 29 this occurs in 26 per cent of all carcinomata of the pancreas) 
or of certain intestinal symptoms (bloody evacuations, hsematem- 
esis, diarrhoeas) may point to the one or other condition in ques- 
tion. None of these symptoms are absolutely diagnostic. 

2. Carcinoma of the Jejunum and Ileum 

On account of its rarity and because, as stated by Treves m , it 
very seldom forms a palpable tumour, carcinoma of the jejunum and 
ileum possesses but little diagnostic interest. Unlike cancer of the 
duodenum, tumours of this portion of the intestine are extremely 
movable. This characteristic may make it difficult to differentiate 
them from cancer of the large intestine, the difficulty naturally be- 
coming greater the nearer the tumour is to the colon. As soon as 
stenotic symptoms appear, however, jejunal carcinoma may be diag- 
nosticated. Enterorrhagia, when present, may be of value in mak- 
ing the diagnosis. 

The subjective symptoms are very similar to those of duodenal 



INTESTINAL NEOPLASMS 339 

carcinoma : colicky pains, increasing marasmus, anorexia, nausea, 
vomiting, and constipation alone or alternating with diarrhoea. 

(J) CARCINOMA OF THE LARGE INTESTINE (EXCLUSIVE OF 
THE RECTUM) 

Although cancer of the small intestine, on account of its infre- 
quency, possesses comparatively little clinical importance the case is 
entirely different with cancer of the large intestine. In the latter, 
not only is there a question of diagnosis per se, but also of the ear- 
liest possible diagnosis, so that a radical surgical operation may be 
performed. For such early diagnosis it is necessary to have in 
mind not only classical cases, but also atypical, irregular forms of 
the disease. 

1. Typical Cases of Carcinoma of the Large Intestine 

Symptomatology and Diagnosis 

Subjective Symptoms. — The most important are intestinal pain, 
vomiting, and disturbances of intestinal function. In concur- 
rence with Rupp, we distinguish the fixed or tumour pain from 
colic or other similar paroxysmal pains. In general, tumour pains 
are dull and localized ; in some instances, however, they may 
radiate toward the back or the sides, toward the thorax, and, if 
the tumour be deeply situated, toward the legs. When not pal- 
pable, the site of the tumour cannot be determined by the locali- 
zation of the pains. 

The paroxysmal pains are of greater importance. Even in 
typical cases their situation, nature, intensity, and duration are ex- 
tremely variable. According to my experience, the situation of the 
pain often points to the site of the tumour ; occasionally, however, 
the pain radiates toward the umbilicus or over the whole abdomen. 
The pain is colicky in character, with remissions and exacerbations ; 
it is slight at its beginning, becomes exceedingly severe as it reaches 
its acme, but soon decreases, to reappear after a longer or shorter 
interval. In one of my cases the remissions lasted precisely ten 
minutes, so that the patient, watch in hand, could exactly foretell 
the next attack. In other cases the paroxysms continue much 
longer, sometimes lasting for hours, with short remissions induced 
by eructations, passing of flatus, or by vomiting. In patients with 
complete stricture the pain is constant. Symptoms of ileus then de- 
velop. Riipp 4 states that the pain is increased directly before def - 



340 DISEASES OF THE INTESTINES 

ecation, especially in stenosis of the lower colon and when purges 
are given. 

The picture is different in cancer of the lower bowel — i. e., from 
the lower portion of the descending colon downward. Tenesmus 
is prominent and characteristic. Since this constitutes one of the 
main symptoms of rectal cancer, further discussion will be deferred 
until the chapter on Carcinoma of the Rectum. 

Constipation and vomiting are very intimately related to the 
paroxysms of pain. Constipation stands in direct relation to the 
pain : the severer the pain the longer the duration and the more 
obstinate the constipation. After a satisfactory evacuation the pain 
disappears ; when the colon is refilled with faeces, paroxysms recur. 
If, in spite of fsecal movements, pain persists, we may be positive 
that the evacuation was insufficient. 

In the first stage of the disease we sometimes find diarrhoea 
alternating with constipation, so that diarrhoea follows after several 
days' constipation. In still other cases constipation is entirely ab- 
sent ; from the very beginning diarrhoea of a nature later to be 
described is present. 

The clinical picture of disturbed intestinal function is com- 
pleted by the appearance of vomiting. The vomiting varies accord- 
ing to the degree of stenosis. It may consist of mucus, stom- 
ach contents, or of feculent or faecal masses. The different types 
of vomiting demonstrate the amount of obstruction. With Riipp, 
I think feculent vomiting, even in severe intestinal stenosis, is 
the exception. I am inclined to believe that the vomiting of 
mucus and of stomach contents is reflex in character, similar 
to that associated with impacted stone, cardialgias, disease of the 
genitals, etc. 

In one of my cases of increasing symptoms of stenosis, hsematem- 
esis occurred directly before the operation. The patient fortunately 
withstood the shock of the hemorrhage. This is an extremely rare 
complication. 

Leaving the last-mentioned symptom (hsematemesis) out of con- 
sideration, there are three cardinal diagnostic symptoms, viz., ob- 
stinate constipation or constipation followed by diarrhoea, colicky 
paroxysms, and vomiting. Increasing experience has shown me 
that, even without the presence of a palpable tumour, these three 
symptoms frequently denote intestinal cancer. The frequency of 
the attacks, the characteristic increase of the paroxysmal pain, 
increasing constipation, the presence of unmistakable cachexia even 



INTESTINAL NEOPLASMS 341 

in this stage, and marked loss of body weight, all point toward 
the correct diagnosis. 

The condition of the remainder of the alimentary canal, particu- 
larly of the stomach, is of secondary importance. In discussing the 
objective symptoms we will describe the results of examination 
of stomach contents. Here we will only mention that, exceptiDg 
during attacks, gastric digestion and appetite may be absolutely 
normal. If there be a long interval between the attacks of colic, 
the patients may gain so much in weight as to mislead one. This 
was particularly true of one of my own cases. In other patients 
— namely, those with increasing stenosis — the appetite very rap- 
idly diminishes. This occurs partly in consequence of the frequent 
paroxysms of pain which rob the patient of sleep, and partly, ac- 
cording to Koenig, in consequence of auto-intoxication from the 
stagnant fsecal masses. 

Objective Symptoms. — These are : tumour, meteorism, visible 
intestinal peristalsis, the character of the faeces, and, in some cases, 
the nature of the stomach contents. 

The palpability of a tumour, which, according to Treves 9 ^, occurs 
in 4-0 per cent of all cases of cancer of the large intestine, constitutes 
one of the most important and decisive diagnostic symptoms. 

The size of the tumour varies considerably, from that of a wal- 
nut to that of a fist, or even of a child's head. It is hard, nodular, 
incompressible, and more or less painful on pressure. According 
to all observers, its main characteristics are active inobility, and in 
connection therewith, change of location and 'position. The fol- 
lowing limitations, however, must be remembered : the mobility of 
new growths of the large intestine is particularly well marked in 
those portions which, because of their long mesentery, themselves 
possess great mobility : these are the transverse colon with its 
flexures, and the sigmoid flexure. The caecum and the ascending 
and descending colon, on account of anatomical peculiarities — 
namely, their short, tense, retroperitoneal mesenteries — are not 
nearly as mobile. Motion of the movable portions of the intestines 
may be restricted by adhesions. Passive and active mobility is 
increased by the weight and pressure of the stagnant intestinal 
contents above the tumour. At times the tumour is covered by 
distended intestine, so that it may be hardly palpable or disap- 
pear entirely ; hence repeated examinations are necessary. This 
condition is very similar to that met with in carcinoma of the 
stomach, in which the tumour may not be felt when the stomach 
23 



342 DISEASES OF THE INTESTINES 

is full, but becomes palpable when that organ is empty. Another 
possible source of error is that the intestines themselves fre- 
quently change their positions, and thus the tumour may often 
be falsely localized. This subject, which is of great surgical im- 
portance, will be considered later. I shall now describe the gen- 
eral principles to be followed in the examination of intestinal 
tumours ; the technic has already been considered (page 84). 

Tumours of the large intestine are best palpated when the bowel 
is empty. When in doubt concerning the site of the tumour, or its 
differentiation from neighbouring organs (stomach, omentum, kid- 
ney, etc.), some aid may be derived from filling the intestines with 
air or water. As already stated (page 85), moderate inflation 
gives us much better information regarding the topography of 
the tumour and the position of the affected segment than ex- 
treme inflation. The latter procedure has its dangers in ulcer- 
ating tumours. In stenosing cancer of the lower portion of 
the large intestine, the fact that air or water repeatedly intro- 
duced always returns, may clear up an obscure diagnosis. Meteor- 
ism is another very important diagnostic symptom. It may be 
localized or general. When localized, it may enable us to de- 
termine the site of the stenosis ; when general, the relations 
between the viscera become uncertain and obliterated. These 
symptoms are more thoroughly treated of in the chapter on Intes- 
tinal Stenosis. 

The occasional occurrence of visible intestinal contractions (" in- 
testinal rigidity," Nothnagel) is of great diagnostic interest. These 
contractions vary from a hardly noticeable rigidity of the intestinal 
coils to a plastic representation of one or more of these, and appear 
synchronously with the paroxysms of pain previously mentioned 
(page 307). Like these, they vary greatly in duration and occur- 
rence. If contractions follow at frequent and regular intervals, 
their recognition is easy. If, on the contrary, they occur at long 
intervals, as in the beginning of stenosis, unless clinically observed, 
their recognition is mostly the result of accident. (See chapter on 
Intestinal Stenosis.) 

The macroscopic appearance of the faeces may be of importance ; 
its value, however, is negative rather than positive. The faecal masses 
are generally not as long nor as thick as in normal stools. The 
stool is passed in small, pointed, narrow, or rounded masses. 
These characteristics are particularly noticeable in the stool from 
enemata. To this there are, however, many exceptions. I have 



INTESTINAL NEOPLASMS 343 

seen an operated case of extreme stenosis from cancer of the caecum, 
in which the calibre of the stool was absolutely normal. After 
passing the stenosis, the faeces must have become increased in cali- 
bre through additions. 

The diagnostic importance of the passing of blood per anum 
has, I believe, been overestimated. In only 1 out of 11 cases of 
cancer of the large intestine did I observe blood in fairly large 
quantity. Slight losses of blood, usually overlooked, may occur 
more frequently. Treves 30 , who has had much experience in 
these affections, has found hemorrhage in but 15 per cent of pa- 
tients with cancer of the colon. Riipp 4 , in a series of 20 cases, has 
found this symptom present in 25 per cent. 

As already mentioned, the dejections may be diarrhoeal in char- 
acter. This occurs not only in cancers of the lower segment of 
the large intestine, but, as soon as marked ulceration begins, also 
in those situated higher up. I have had two opportunities to 
make regular examinations of such stools. They are mottled red 
in appearance, and at times contain macroscopic, easily recognis- 
able admixtures of pus, which sometimes forms as a yellow sedi- 
ment, sharply contrasted with the remainder of the dejection. The 
evacuations were very foul, and always of a distinctly alkaline reac- 
tion. Besides red blood-corpuscles, microscopic examination showed 
many pus cells in every field, giving the impression of an abscess. 
There may be 8, 10, or 20 such dejections daily. Occasionally the 
pus may not be so prominent, and the stools are more bloody in 
character, but careful examination will always reveal pus in macro- 
scopic or microscopic quantities. 

As shown by cases of Potain 31 and Wunderlich 32 , fragments 
of the tumour may very rarely be passed per rectum, a fact which 
will at once establish a positive diagnosis. In a case reported by 
Elcolaysen ^ there was prolapse of a carcinoma of the sigmoid 
flexure. These cases, however, are so extremely infrequent that as 
a rule they may be left out of diagnostic consideration. Despite 
careful search — both in spontaneously evacuated stool and in 
that after rectal irrigation — I have never found any tumour par- 
ticles. Nevertheless, in all obscure diseases of the intestines in 
which blood and pus are present in the evacuations, I would advise 
frequent rectal irrigations for this purpose (see page 87). 

The examination of the stomach contents may sometimes give 
facts of diagnostic importance. In cancer of the colon, as far as 
I know, no such examinations have yet been made. In three 



344: DISEASES OF THE INTESTINES 

patients in whom I made the tests, the gastric motility was con- 
stantly normal. In one case there was absence, and in the two 
others an abundance of hydrochloric acid. I lay particular stress 
upon the maintenance of good gastric motility in cancer of the 
colon, since this, as is well known, suffers quite early in cancer of 
the stomach. 

2. Atypical Cases of Carcinoma of the Large Intestine 

There are many atypical cases in which the clinical picture of 
cancer of the large bowel is obscured; but, since their detailed 
knowledge may enable us to make a probable diagnosis, they 
must be considered. As in cancer of the stomach, there is 
often an entire absence of characteristic symptoms : the patient 
emaciates, loses appetite, presents indefinite dyspeptic symptoms 
and continues to lose strength, and finally dies. Autopsy shows 
an intestinal cancer. Such obscure cases occur in all segments 
of the gastro-intestinal canal. Surgical literature contains many 
examples. 

In a second and fairly large variety of cases there is sudden, 
absolute intestinal obstruction with all its serious sequences. I 
believe these cases are more easily diagnosticated. As early as 
1864: Bamberger 34 described one. After a meal consisting of 
lentils, the patient, till then an apparently strong, healthy man 
of forty, was suddenly attacked with severe abdominal pain, marked 
tympanitis, constipation, and vomiting. Death occurred on the third 
day. The autopsy showed a circular, carcinomatous stricture of 
the sigmoid flexure with only moderate stenosis, but the intestine 
above the tumour was entirely occluded by the undigested lentils. 
Riipp 4 has described a series of similar cases coming under his own 
observation, characterized by acute intestinal occlusion from cherry 
stones, bone splinters, inspissated fsecal masses, and apple seeds. 
Yery acute intestinal obstruction may also result from adhesions 
of the tumour to other intestinal coils, whereby kinking or twist- 
ing of the bowel is produced. 

As exemplified by a case of Riipp, impacted gallstones in the 
small intestine may cause the sudden appearance of acute symp- 
toms of obstruction in a latent cancer of the large bowel. Such 
instances might be further multiplied. Even without such direct 
mechanical causes, symptoms of complete obstruction may (at 
least according to the patient's own statement) be induced by 
dietetic errors in healthy or rather, apparently healthy individ- 



INTESTINAL NEOPLASMS 345 

uals. These acute attacks of intestinal obstruction are doubt- 
lessly preceded by preliminary symptoms which are only slight, 
and impress the patient but little. As far as the patient's 
serious condition allows, the physician must inquire for symp- 
toms which may have had the character of an incipient intes- 
tinal stenosis. 

Differential Diagnosis 

Without doubt the presence of a well-defined tumour gener- 
ally facilitates the diagnosis ; although even then error may be una- 
voidable. 

The question whether the tumour is a real neoplasm or only 
impacted faeces, may sometimes produce the greatest diagnostic 
difficulties. In the general division (page 76) we have described 
the various methods by which mistakes may usually be avoided. 
We have there stated that faecal accumulations above the stenosis 
may make a neoplasm appear much larger than it really is. 

Tumours of the ccecum, beginning like appendicitis, with fever, 
pain on pressure, and resistance in the ileo-caecal region, often lead 
to diagnostic errors. But these tumours do not disappear when the 
acute symptoms have passed ; they become larger and more nodu- 
lar, the patient emaciates, and dies in extreme marasmus, or he 
may succumb to symptoms of acute intestinal obstruction. Several 
such cases have been described by Bamberger m and Krausshold 36 . 
Schede 37 has observed a medullary cancer superimposed upon an 
old, irregular perityphlitis. On the other hand, Schede and Kiche- 
lot and Hartmann 38 have operated on cases in which, instead of 
an expected cancer of the caecum, they found only inflammatory 
perityphlitic products. These cases demonstrate that, even where 
a tumour can be felt there may be difficulties. 

If there be an intestinal tumour the further question of malig- 
nancy or benign ancy will have to be determined. Regarding 
benign tumours, fibromata and myomata of the intestines are 
very rare, and only exceptionally produce the severe symptoms 
of malignant growths. The differential diagnosis between sar- 
comata of the large and small intestines may also have to be made. 
It is discussed under the heading Symptomatology, to which the 
reader is referred. 

We have already discussed the interesting and frequent question 
of differentiation between cancer and tuberculosis of the caecum 
(p. 277). 



346 DISEASES OF THE INTESTINES 

Besides the difficulties already mentioned, tumours of other or- 
gans may give rise to errors in diagnosis. For example, von Berg- 
mann 39 once diagnosticated a tumour as cancer of the caecum ; on 
operation it was found to be a cancer of the stomach adherent to 
the right iliac fossa. Hahn 40 reports a case of a young man of 
nineteen with a nodular tumour in the right side which was thought 
to be an enlarged kidney. Laparotomy (Simon's incision) showed 
the right kidney normal and in normal position. Upon opening 
the peritoneum there was found a tumour of the ileum and caecum 
the size of a child's head. Examination proved it to be a small 
round-celled sarcoma. Czerny 41 and von Esmarch ^ report similar 
errors. In a doubtful case in a woman, in which the diagnosis 
rested between tumour of the caecum and floating kidney, Salzer **, 
on vaginal examination, was able to differentiate by involuting the 
soft layers between his fingers and the tumour; he could intro- 
duce his fingers into the ileo-caecal opening from the small intes- 
tinal side, and thereby recognised the neoplasm as one of the caecum. 
These examples, particularly abundant in surgical literature, might 
be multiplied. 

The diagnostic difficulties are increased when tumours of the 
intestine (generally the large intestine) are complicated by displace- 
ment of the different intestinal segments. The obstacles are so 
great that sometimes even an operation will not clear up the 
cases. Thus, Passler 44 reports a case from Curschmann's clinic 
in which a carcinomatous stenosis of the hepatic flexure of the 
colon was clinically diagnosticated. Autopsy revealed a carcinom- 
atous degenerated caecum, which was situated high up under the 
liver, and, owing to a congenital absence of the ascending colon, 
communicated directly with the transverse colon. During an oper- 
ation for carcinoma of the large intestine, Israel ^ thought he was 
dealing with the descending colon, while, in reality, he was oper- 
ating upon a displaced transverse colon. 

Many more examples might be mentioned. They should teach 
us to be very cautious in diagnosticating the site of a neoplasm. 
It may be necessary to differentiate between cancer of the large 
intestine and chronic intussusception. The following symptoms 
point to intussusception : sudden onset, passing of blood per rectum, 
shape of the tumour (smooth, cylindrical) and its spontaneous mo- 
tility, the age of the patient. None of these symptoms is pathog- 
nomonic, and only by careful consideration of the separate data 
can a mistake in diagnosis be avoided. Diagnostic difficulties may 



INTESTINAL NEOPLASMS 347 

become considerable when a tumour can not be palpated, and when 
the usual characteristic symptoms are absent. However, when 
there is a good clinical picture a probable diagnosis can be made. 
To begin with, it is necessary to establish the existence of an intes- 
tinal stenosis. If the symptoms of the latter are well marked, 
we may generally arrive at the correct diagnosis by exclusion. 
Aside from subjective symptoms, it is necessary to keep in mind, 
first of all, the appearance of visible intestinal peristalsis ; one 
single coil of intestine discovered in the act of peristalsis and 
rigidity may clear up an otherwise doubtful condition. For the 
different symptoms which occur in the several varieties of intes- 
tinal stenosis I refer the reader to the chapter on Intestinal Ste- 
nosis. 

If intestinal stenosis is absent as a symptom, the diagnosis is 
only possible from the presence of other objective signs, particularly 
blood and pus in the stools. As E"othnagel * states, the only other 
disease besides cancer which can come into question when bloody, 
purulent matter is found in the dejections, is chronic dysentery. 
" Since dysentery is generally easily recognised, the importance of 
this type of dejection in the symptomatology of intestinal cancer is 
quite manifest." 

The differentiation is not always easy, as the following example 
will show : 

Mr. A. , merchant, thirty-nine years old, from Hanover. Parents and grand- 
parents died at an advanced age ; has one brother alive and well. Had measles 
when a child. When thirteen years old had malaria (probably tertian type) 
for eight to nine weeks, later disappearing entirely. At twenty-four had hem- 
orrhoids, which were successfully ligated. Otherwise the patient was well 
until 1896. At that time he suffered with bowel complaint — frequent tenesmus 
without evacuations, abdominal pain, alternating constipation and diarrhoea. 
Blood or pus had not been observed in the stool. There was then no marked dis- 
turbance of general health; the patient was not confined to bed; he was able to 
attend to his business. Following the use of hot enemata the stools regained 
their normal consistency, and remained regular until November, 1897. Patient 
then for the first time noticed the occurrence of frequent painful rectal tenesmus. 
The dejections were liquid, had a very bad odour, and were mixed with blood 
and mucus. The tenesmus and number of dejections gradually increased. 
Patient began to have fever; he emaciated and lost his previous good appetite. 
I first saw him on February 10, 1898 ; the status prcesens was as follows : Ex- 
tremely pale, emaciated man, of medium size and cachectic facies. No enlarged 
glands, no oedema, no exanthema; tongue dry, clean, red; throat showed noth- 



Loc. cit. (ref. 6), p. 236. 



348 DISEASES OF THE INTESTINES 

ing special; thorax long and narrow, percussion note normal; vesicular breath- 
ing present all over the lungs. Heart sounds normal; heart of normal size. 
Pulse of very low tension, small, somewhat irregular, 120 beats per minute. 
Temperature, 36° to 37° C. 

Abdomen. — The entire abdomen unequally distended. There is distention, 
particularly localized below the umbilicus. Occasionally there are seen indica- 
tions of intestinal peristalsis without rigidity, particularly in the ileo-cascal 
region. No tumour can be felt. Palpation of the ileo-cascal region is very 
painful. Hepatic and splenic dulness entirely absent, being obscured by the 
tympanitic intestinal percussion note. Slight splashing sounds in the epi- 
gastrium. Rectal examination negative. Rise of temperature between 38° 
and 39° C. 

Since his stay in Berlin the patient has had continual rectal tenesmus. 
There are 6 to 8 stools daily, consisting at first mainly of pus and blood, with 
only a small amount of faecal matter ; they have a very foul and fetid odour. 
Microscopical examination shows innumerable large and small pus ceils and 
blood cells. No amoebae. Repeated examinations for tubercle bacilli are nega- 
tive. Pus in the stool continues during the course of the disease. 

Urine contains a moderate amount of indican. Quantity of urine, 500 cubic 
centimetres in 24 hours ; it is brownish-red and of high specific gravity. 

The course of the disease was as follows : There was quite apparent loss 
of strength; at first fever, later temperature is normal or subnormal. Despite 
this the pulse is always 120-130, and very small; tongue clean but dry; abso- 
lute anorexia, troublesome thirst ; the main subjective symptom is tenesmus; 
the main objective symptoms are meteorism, pain in the ileo-caecal region, 
purulent dejections, as well as the patient's general septic condition (septic 
intoxication). With symptoms of increasing marasmus and occasional somno- 
lence, the patient died, February 26, 1898. 

Autopsy, February 27th, performed by Dr. Hans Kohn, of Berlin. Very 
much emaciated corpse, presenting nothing special externally. Abdomen mod- 
erately tympanitic. The thin abdominal walls coloured green. Upon opening 
the abdomen all the intestines were found to be distended with gas, and were 
all in normal position except the sigmoid flexure, which lay parallel with the 
pubic bone until it reached the right iliac fossa, where it was slightly adherent. 
It was also adherent to the anterior circumference of the pelvic outlet. The 
omentum was almost entirely free from fat and wreathlike in shape, and also 
adherent to the pelvic outlet. After the omentum is thrown back the gen- 
eral intestinal serosa is moist and pale, excepting over the sigmoid, where 
it is very dark red. Attempting to loosen and free the sigmoid, the whole 
intestinal wall easily tears, disclosing an abscess cavity filled with pus and 
about the size of a hen's egg. The walls of the cavity are mainly formed 
by the sigmoid flexure, and partly by the anterior pelvic floor. It communi- 
cates directly with the lumen of the bowel; the size of the communication can 
not be positively determined because of the extremely brittle condition of the 
intestinal wall. The dark discoloration of the intestinal serosa extends up- 
ward to about the beginning of the descending colon, whence it gradually 
becomes pale and disappears. With the exception of the beginning of the 
ascending colon, which is filled with faecal matter, the large intestine is 



INTESTINAL NEOPLASMS 349 

found to be empty, or rather to contain only gas. The mucous membrane 
of the descending colon is pale yellowish-white in colour, and is uniformly 
covered with thick pus. In numerous places there are ulcerations, irregu- 
lar in shape, with smooth edges, and extending to the muscularis. Above, 
the ulcers may be followed into the middle of the transverse colon, where 
they become smaller. The smallest are the size of lentils, the largest the 
size of a 50-cent piece. They are not round, but irregularly shaped. Below, 
the ulcers increase in size, and the mucous membrane becomes gradually more 
deeply injected. In the sigmoid flexure the greater part of the mucous 
membrane is destroyed. Here there are areas of eroded mucous membrane 
about 1.2 centimetres long, 1 to 2 centimetres broad, and about 1 to 3 cen- 
timetres thick. 

As just stated, areas of mucous membrane and muscularis are entirely 
destroyed. Between these the mucous membrane is covered by reddish-yellow 
thick pus. These changes extend into the rectum. The mucous membrane 
of the upper portion of the large intestine, and of the whole of the small intes- 
tine, is anaemic. The small intestine contains only small quantities of semisolid 
masses; the contents of the caecum are of normal consistency, formed, rich 
in fat ; but in the middle of the ascending colon the contents become semi- 
solid. As already remarked, the intestines situated farther down are empty. 

Isolated lymph nodes the size of lentils are found in the walls of the 
lower segments of the large intestine. Some of the mesenteric glands are 
swollen to the size of beans. There is no thrombosis of the blood-vessels 
supplying the descending colon. 

The liver is quite small and soft ; on section it is pale, reddish-yellow, and 
cloudy ; it contains no abscesses. 

The spleen is somewhat enlarged, bluish-red, and soft. 

The right kidney, normal in size, but soft and grayish-red on section ; very 
cloudy. 

The clinical diagnosis lay between carcinoma, tuberculosis of 
the large intestine, and chronic dysentery. Since tubercle bacilli 
were never found, and since other signs of tuberculosis were absent, 
the diagnosis was limited to the two other possibilities — carcinoma 
and dysentery. 

In my opinion, an epicritical examination of the case presents 
no possibility of a positive differentiation ; as against cancer it 
might be maintained that a tumour was absent. But a tumour, if 
present, would have been obscured by the marked abdominal dis- 
tention. As regards the fever, that would have spoken more in 
favour of tuberculosis than of cancer. As to the age of the patient, 
there is no special limit within which cancer may occur, particu- 
larly cancer of the large intestine. Finally, the course of the 
disease and its acute invasion spoke rather for than against a 
malignant neoplasm. 



350 DISEASES OF THE INTESTINES 

I might describe an analogous case, very similar throughout 
except that toward the end of life there developed to the right 
of the bladder a tumour, whose diagnosis caused expert clin- 
icians, as well as myself, many difficulties. These difficulties 
were increased by the fact that the patient dated his symptoms 
some fifteen years back. Operation showed a sloughing carci- 
noma of the sigmoid flexure, which had displaced the latter to 
the right. 

From these two cases it follows that, in the absence of a tumour, 
the differential diagnosis between dysentery and carcinoma may 
cause great difficulties, which, so far as I can see, cannot, in the 
present state of medical knowledge, be overcome. 

Finally, cancer is to be differentiated from the intestinal neu- 
roses. I have observed two cases which for a long time presented 
symptoms of nervous intestinal disturbance, and whose malignant 
character was revealed only late in the disease. Both patients had 
suffered for years from habitual constipation, and both were marked 
hypochondriacs on the subject of defecation. Contrary to my own 
opinion, and quite correctly, they looked upon their last complaint 
as of a very serious nature. Brinton's excellent dictum regarding 
cancer of the stomach is also true of cancer of the intestine: 
" Obscure in its symptoms, frequent in its occurrence, fatal in its 
events." 

(c) CANCER OF THE RECTUM 

Cancer of the rectum is recognised more easily than cancer of 
any other portion of the intestines, and offers the most favourable 
chances for cure. 

Symptomatology and Diagnosis 

It is best not to separate the subjective from the objective 
symptoms, but to consider them together. The subjective symp- 
toms relate to the disturbances of defecation, and at the beginning 
they may be so indefinite that the patient may not seek medical 
advice.* 

Defecation is interfered with ; evacuation occurs only after strong 
action of the abdominal muscles, and the stools have no longer the 
normal cylindrical form, but are flattened and of small calibre. 

* Occasionally apparently remote symptoms may point to the real source of 
trouble — e. g., obstinate sciatica. 



INTESTINAL NEOPLASMS 351 

They resemble sheep dung, and are often fragmentary. It thus 
happens that patients have frequent daily evacuations, but each 
time these are small, unsatisfactory, and are accompanied by very 
much straining. Closely related therewith is a feeling of fulness, 
weight, and pressure in the small pelvis, which always impels the 
patient to attempt to evacuate his bowels. The resultant move- 
ments, though small, afford temporary relief. 

Gradually painful tenesmus develops, together with the increas- 
ingly frequent and scanty dejections. These may remain formed, 
but usually consist of thin fluid masses with an exceedingly nau- 
seating, fetid odour. At this time the dejections may contain mu- 
cus, blood, and pus. 

As the disease progresses the symptoms of a stenosis of the 
rectum become more marked ; tenesmus is continuous, or has 
only short remissions. The stools become more numerous, more 
liquid and less in quantity, and admixtures of pus, mucus, and 
blood are more often found. The symptoms continue during the 
night and cause insomnia. The appetite decreases perceptibly, 
the general health begins to fail, and the patient begins to look 
cachectic. 

The objective examination consists, first and foremost, of a digi- 
tal exploration of the rectum, and then of an examination of the 
evacuations. 

At varying distances from the anus the examining finger en- 
counters irregular, nodular, thickened masses which are immedi- 
ately recognised as neoplasms. A more careful examination will 
distinguish two types. In cancers situated high up, the finger has 
the feeling as if entering a hard, rigid cylinder, above and to the 
sides of which is attached, as it were, a vaginal vault. Generally 5 
the finger cannot pass any farther through this pseudo-vaginal 
opening ; with a little force it may enter a narrow irregular cylin- 
der. On withdrawing the finger there are traces of blood and a 
characteristic fetid odour. 

Kraske 9 states that where the carcinoma is limited to the wall 
of the rectum, and is not adherent to the surrounding tissues, one 
may obtain the sensation of ballottement with the end of the finger. 
I have found this symptom only once, but this infrequency is pre- 
sumably due to the fact that I generally see cases in the more 
advanced stages of the disease. 

In cancer situated low down in the rectum there is usually no 
marked invagination. The finger enters a stiff walled cavity which 



352 DISEASES OF THE INTESTINES 

is sharply defined against the smooth mucous membrane, both above 
and below. In other cases there are circular or semicircular tu- 
mours, with protuberant, serrated (cockscomblike) edges which pro- 
ject beyond the normal mucous membrane. 

The diagnosis of the presence of cancer of the rectum is not 
sufficient ; it is also necessary to know the extent of the tumour, its 
mobility, and the presence or absence of complications. The ques- 
tion of mobility is of the greatest surgical significance. According 
to Kraske, the question of operation depends more on the mobility 
of the growth than on its size. 

The main complication is rupture into the neighbouring vis- 
cera (bladder, genitals). We will not discuss the rarer complications 
here. 

In every case of rectal carcinoma the liver ought to be examined 
as a matter of routine. Metastases occur most frequently in this 
organ, a fact which is naturally of great importance in the question 
of radical operation. Ordinarily the examination of the faeces is 
unnecessary; but in doubtful tumours, or in those reached with 
difficulty, such an examination may, as- I maintain in opposition to 
Hochenegg ^ clear up the clinical picture to a considerable extent. 
The external appearance of the faeces may either be that of stenotic 
stools (e. g., ribbonlike, spiral, short cylinders embedded in a thin, 
apparently homogeneous, bloody, or purulent ground substance), 
or they may consist entirely of fluid or semifluid masses, or, in ad- 
vanced cases, of pus and blood. In cases not far advanced, where 
the cancer is situated high up or where the differential diagnosis 
lies between cancer and benign neoplasm, the abnormalities of the 
faeces just described are of less significance than the demonstration 
of small, microscopic admixtures of pus. 

The diagnosis, therefore, will not be difficult in the majority of 
cases, particularly to the physician who makes it a rule to examine 
the rectum digitally not only in patients with symptoms referred 
to the rectum, but in every case of intestinal disturbance. There 
are, however, isolated instances in which there will exist doubt re- 
garding the nature of the rectal affection. These necessitate a short 
discussion on differential diagnosis. 

Differential Diagnosis 

By careful and repeated rectal and vaginal examinations it is 
very easy to differentiate tumours of the rectum from tumours of 
the prostate or of the female genitals, pelvic abscesses, etc. Polypi 



INTESTINAL NEOPLASMS 353 

of the rectum will only exceptionally cause diagnostic difficulties. 
Owing to their extreme rarity, myomata of the rectum will scarcely 
come up for consideration. Differentiation from rectal sarcoma 
may give rise to error ; in contrast to cancer, the sarcomatous 
tumour has a smooth surface and there is no tendency to ulcer- 
ation. 

It may be somewhat more difficult to distinguish between 
fibrous syphilitic stricture of the rectum and carcinoma. We shall 
more fully discuss the symptomatology of syphilitic stenosis of the 
rectum in the chapter on Diseases of the Rectum, and therefore 
limit ourselves here to a few brief remarks. 

With Kraske, I believe that the differentiation is not difficult. 
With reference to the diagnosis, Kraske says the following, which 
corresponds with my own experience : " In syphilitic proctitis the 
stenosis is produced by cicatrization and is a real stricture. The 
difference between the two forms of stenosis is also very evident to 
the examining finger. The syphilitic ulcerations never have the 
hard, protuberant edges that are found in the carcinomatous. In 
contrast to cancer, syphilitic ulcers are generally multiple, and are 
separated from one another by areas of healthy or cicatrized mucous 
membrane. The syphilitic infiltration begins mainly as a diffuse 
process, while cancer is for a long time more circumscribed. This 
last fact is particularly evident in the condition of the surrounding 
tissues and organs. Syphilitic ulcerations very often produce peri- 
proctitis, external abscesses, and fistulge which rupture externally, 
while this very rarely occurs with cancer. In my own experience 
it has never occurred. It is true that in cancer situated low down 
there may occasionally be a rupture through the skin in the neigh- 
bourhood of the anus, but the character of such an opening, par- 
ticularly its infiltrated margin, will at once show that it is not a 
fistula arising from a periproctitic abscess, but is a direct rupture 
due to the growth of the cancer toward the surface." If we add 
further that syphilitic stenosis is essentially chronic, is more fre- 
quent in women than in men, is present much earlier in life than 
cancer, we have sufficient facts to assist us in most cases. Where, 
despite the above, diagnostic difficulties are encountered, there is 
the final recourse to excision of a piece of the growth for examina- 
tion. Even this may not give positive results. 



354 DISEASES OF THE INTESTINES 



Complications of Intestinal Cancer 

The most important complications are produced by the tumour 
itself. As already mentioned (page 300), the tumour may become 
adherent to the bladder, uterus, ovaries, stomach, etc. There may 
be a discharge of fetid or faecal matter through these organs. I have 
seen two cases of rupture of cancer into the bladder with the rapid 
development of a purulent cystitis with extremely feculent urine. 
When rupture into the uterus or vagina takes place, faecal masses 
empty themselves through the genital cloaca. Where a communica- 
tion between the stomach and large intestine is established the condi- 
tion of lientery, known to the older writers, develops. In consequence 
of such a fistula there is faecal vomiting, and the passing of entirely 
undigested food per anum. Rarely, carcinoma may rupture through 
the abdominal wall. Finally, there may be a rupture of the carci- 
noma into the retroperitoneal tissue, with the formation of faecal 
abscesses. The latter may cause a general septic peritonitis, or 
may lead to abscesses pointing at different places — e. g., Pou- 
part's ligament, the lumbar region, etc. The perforation, per se, 
is practically the most important as well as the most significant 
complication. This may occur very suddenly, without any warn- 
ing, when the patient seems to be improving. In one case per- 
foration occurred during the time the attendants were giving the 
patient an enema of water. Straining at stool may cause this un- 
expected accident. 

Finally, death may be caused by rarer complications, viz., aspi- 
ration pneumonia, embolism and venous thrombosis, uraemia, metas- 
tases in other organs, peritoneal carcinoma, terminal hemorrhage 
of the intestine, stomach, etc. 

Treatment of Intestinal Cancer 

In the ordinary sense of the word a real cure of an intestinal 
cancer does not exist. Under favourable conditions, to be later 
more fully described, extirpation of the tumour may prolong life 
for months, or years, but even in these cases a fatal termination 
cannot be prevented. With but few exceptions, surgical inter- 
ference is the best and most practical of all the palliative, life- 
prolonging remedies. In most surgical operations there is un- 
deniably a direct relation between the object to be gained and 
the severity of the operation. He who risks much may occa- 



INTESTINAL NEOPLASMS 355 

sionally expect a successful result even under unfavourable cir- 
cumstances ; he who does not take such risks cannot reckon on 
great results. 

In hopeless cases we must limit ourselves to palliative treatment. 
The various palliative measures depend upon the site of the tumour 
and the clinical syndrome. 

They consist in 

1. Increasing the patient's strength. 

2. Removal of the stenotic symptoms present in the great ma- 
jority of cases. 

3. When the last object is only partially accomplished or im- 
possible, relief of the pain and other symptoms caused by the ste- 
nosis. 

4. Treatment and relief of complications. 

It is quite apparent that the above division is somewhat sche- 
matic, since the several symptoms may change or become interde- 
pendent. For the better survey of the subject we shall, however, 
adhere to this grouping. 

1. In many cases the attempt to increase the strength and 
nutrition succeeds even though temporarily. For apparent reasons 
we are least successful in cancer of the small intestine, and most 
successful in cancer of the rectum, while cancer of the large intes- 
tine occupies a middle ground. 

In cancer of the small intestine the diet is similar to that 
in cancer of the stomach. It consists in the frequent adminis- 
tration of small quantities of fluid or semisolid nourishment of 
the highest caloric value. To stimulate the appetite we must 
consider the wishes and peculiarities of the patient. We should 
not hesitate to give patients such food as may refresh and please 
them, provided it does not aggravate the intestinal lesion (von 
Ley den). 

The underlying principles have already been given (page 151), 
and it will only be necessary to describe several minor details. 
In carcinoma of the duodenum those foods are most appropriate 
which, because of their physical character, allow of a large con- 
centration of soluble nourishment. Milk, albumin, carbohydrates, 
and fats, percentages of which may be increased at will, occupy the 
first place. 

The albumin may be increased in amount by the addition of 
commercial albumin preparations ; the carbohydrates, by the addi- 
tion of flour in any of its many well-known forms ; the fats, by 



356 DISEASES OF THE INTESTINES 

addition of cream in amounts depending upon the tolerance of the 
stomach and the degree of stenosis. Both the albumin and car- 
bohydrates can be simultaneously increased by adding leguminous 
flour. 

The artificial albumin preparations, often tiresome in dyspeptic 
conditions, may be alternated with natural egg albumen. Vege- 
table, meat, and fish soups in their many combinations may be given 
to satisfy the patient's desire for change of diet without producing 
an appreciable diminution of the general nutrition. Solid meat and 
fish preparations should be administered in their most easily digest- 
ible forms, or had better be avoided altogether. Vegetables and 
fruits, white bread, zwieback, sweetened crackers, all of which have 
been finely divided or thoroughly cooked, may be allowed. Raw 
fruits, vegetables, tubers, and similar articles are to be absolutely 
forbidden. We shall return to this subject. 

The food given to patients with cancer of the rectum and other 
portions of the large intestine may be much more varied. As we 
have already seen, the stomach functions may be absolutely normal in 
these cases, and a similar normal condition may be assumed to exist 
in the upper part of the intestinal canal. The diet must be of the 
greatest caloric value, but the food need not necessarily be given in 
small quantities and with frequent intervals. With the exceptions 
soon to be stated the foods may be given in their natural form. 
Meat, when minced, is often easily digested. Soups, particularly 
when concentrated, are good though by no means absolutely neces- 
sary forms of diet. The same may be said of milk, though strength- 
ening the patient. Unfortunately milk is not always well borne ; 
in such instances it may be tried in its various preparations (kefyr, 
sour milk, koumyss, etc.). 

Vegetables, which in their natural form are not finely divided, 
must always he strained, so as to prevent any possible mechanical 
obstruction of the lumen of the intestine. 

For this reason vegetables which cannot be mashed should be 
absolutely excluded ; in fact, I regard it as a distinct therapeutical 
error to allow patients with intestinal stenosis to eat unstrained len- 
tils, peas, beans, asparagus, raw fruit, cabbage, etc. This same is 
true, possibly more so, when applied to raw compotes, or such as are 
not rendered fully pultaceous, or compotes and fruit containing 
small seeds. As shown above, the patients may pay for such in- 
discretions with their lives. 

2. Next to abundant nourishment, the physician must try to 



INTESTINAL NEOPLASMS 357 

induce increased intestinal peristalsis, brought about, if possible, 
by dietetic means. We have fully described this in the General 
Division (see page 151, etc.). 

To a certain degree diet may remove the symptoms due to the 
stenosis. The underlying dietary principles have already been con- 
sidered in the General Division, and in the chapter on Intestinal 
Stenosis. The functional disturbances from intestinal cancer re- 
quire great caution, for to the putrefaction produced by the stenosis 
there is often added that resulting from the intestinal ulcerations. 
Thus, instead of the normal contents, the bowel contains a fetid 
mixture, uninfluenced by intra-intestinal medication. It is advis- 
able to get rid of this putrescent material as soon as possible by 
lavage of the stomach in cancer of the upper intestinal segments, 
and by appropriate laxatives when the cancer is in the lower seg- 
ments of the intestine. 

3. When the above measures fail to relieve the symptoms of 
stenosis, the use of narcotics is oftentimes unavoidable. We must 
again refer the reader to the chapter on Intestinal Stenosis and to 
the General Division. 

In the operative treatment of intestinal carcinoma the following 
indications are particularly to be considered : 

1. Extirpation of the tumour. 

2. The removal of stenotic symptoms. 

3. Kelief of intestinal obstruction which may develop during 
the course of the disease. 

Before discussing the indications, we must briefly narrate the 
results of intestinal surgery, as found in the numerous clinical and 
statistical reports. 

The medical practitioner, even though thoroughly acquainted 
with the various phases of the disease, will rarely have an extensive 
personal experience therewith. Hence, notwithstanding the well- 
known and oft-repeated fact that statistics are not always complete 
or reliable, it is necessary for him to study statistical reports. 

In the first place, the results of operations for cancer vary 
with the kind of operation. According to Wolfler 47 , the latest 
statistics on intestinal resection for new growths give the high 
mortality of 54 per cent, while the entire mortality of intestinal 
resections for all causes is only 39.5 per cent. As pointed out by 
many writers (Mikulicz and others), this mortality is influenced 
by the nature of the disease. In this connection it is worthy of 
notice that better technic shows no improvement in results. In 

24 



358 DISEASES OF THE INTESTINES 

1890 Billroth 48 reported a mortality of 50 per cent; Czerny 49 , a 
similar mortality in 1892. Nicolaysen ^ gathered together 121 cases 
from literature, with a mortality of 48 per cent. My own expe- 
rience is limited to 8 operations for cancer of the large intestine 
(caecum, 5 ; hepatic flexure, 2 ; sigmoid flexure, 1), of which 3 
were resected. One case, cured by resection, is now 'alive, four 
years since operation ; 2 died several days after operation ; intes- 
tinal anastomosis was performed in 2 cases (they lived eight or 
nine months) ; in 2, enterostomy (colostomy) was performed during 
an attack of acute intestinal obstruction; in another, exploratory 
laparotomy. 

The chances for a permanent cure after resection, are evidently 
more favourable in intestinal than in gastric cancer, because the 
former has a lesser tendency to metastasis. Wolfler reports a 
case of a man operated on for cancer of the sigmoid flexure in 
1879 who was still well in 1896. Rupp 4 reports a case of a 
patient from Kronlein's clinic, who after nine years had had no 
relapse. From reports kindly sent me by Prof. Korte, of Berlin, I 
learned that an almost hopeless case of cancer of the cecum had 
been operated on and had now been well over niue years. There 
are many other similar accounts of patients operated on for cancer 
of the large intestine who remained cured for a number of years 
(Billroth, Konig, Czerny, Wolfler, and others). 

The results from incomplete enterostomy (the entero-anasto- 
mosis of Maisonneuve) are much more favourable. Wolfler 47 
cites statistics of Schloffer, which show that in 47 cases of intes- 
tinal stenosis the mortality from this operation was only 30 per 
cent. The duration of the cure seems on the whole to be favour- 
able. In one case of Korte * (cancer of the splenic flexure) the 
patient lived three and a quarter years after entero-anastomosis ; 
he died finally of metastatic cancer of the liver. The result in 
these cases is to be judged by the degree of restoration of function. 
Unfortunately there are only a few useful reports in this connection. 
In the two cases I have mentioned above the results were not satis- 
factory. The patients gained in weight, although the intestinal 
pains were in no wise decreased. In one of the cases evidences 
of intestinal stenosis reappeared after a time. 

The results of operative treatment of rectal cancer require 
special mention. We distinguish the following methods : 

* Personal report. 



INTESTINAL NEOPLASMS 359 

1. Extirpation of the rectum by the perineal method, practised 
in rectal tumours situated low down. 

2. Extirpation by the sacral method, first introduced by Kraske 9 
for rectal cancer situated high up ; the operation has been improved 
by the further modifications of Hochenegg 51 , v. Heinecke 5 ' 2 , W. 
Levy 53 , Schlange 54 , [Bardenheuer] and others. 

3. The vaginal method recently introduced byRehn 55 for the 
removal of rectal cancer in women. 

There are a number of statistics regarding the results from the 
first of the above-mentioned surgical procedures. We limit our- 
selves to the very extensive statistics from Czerny's clinic 56 , which 
have the advantages of presenting the results of only one individual, 
of covering a long period of time, and of including both methods 
of operation. From 1878 to 1891 152 cases of rectal cancer came 
under observation, of which number radical operation was per- 
formed in 109, 21 were curetted, 12 were inoperable, and colotomy 
was performed in 8. Of 83 cases operated by the perineal method, 
3 died immediately (that is, 3.6 per cent). Of 66 cases operated on 
by the sacral method, 9 died (13.61: per cent). The total mortality 
of the 109 cases was 10, or 9.1 per cent. Of 99 patients radically 
operated on, 21 lived two years or more ; 15 lived three years or 
more ; 8, five years and over ; 1, eighteen years ; another, sixteen 
years ; others, thirteen and three quarters, eleven and a half, eight 
and three quarters, and six and three quarters years. The frequency 
of recurrence after extirpation is very variously estimated by the 
different authors. The percentage ranges between 41.6 per cent 
(Kraske) and 73.3 per cent (Lovinsohn). According to Czerny 57 
these figures underestimate the facts ; he claims that 20 to 25 per 
cent of radically operated cases remain free from recurrence for 
over two years, and that the majority of these remain permanently 
cured. The danger of recurrence is diminished by the sacral method 
of operation, since by this procedure the lymph nodes in the sacral 
fossa can also be removed. But the value of extirpation of the 
rectum is also determined by the functional results obtained. Un- 
fortunately, there are not sufficient statistics in this connection to 
permit of proper judgment. The functional results depend upon 
whether the sphincter ani must be sacrificed or not. When the 
sphincter can be saved the functional result is satisfactory, even 
though the sphincter rarely contracts as well as the normal. When 
the sphincter has been sacrificed, the condition of the patients is 
extremely unfortunate, since they have absolutely no control over 



360 DISEASES OF THE INTESTINES 

the flatus or fluid stools. Solid faeces can usually be controlled by 
the formation of an elastic obstruction near the former third 
sphincter, the rectum being then daily irrigated. 

Eegarding extirpation of the tumour, whether of the small in- 
testine, colon, or rectum, the operation must be radically performed 
in those cases in which the tumour is well circumscribed and mov- 
able, and where no metastases are found. 

As is well known, apparently favourable cases may, when 
laparotomized, present evidences of metastases, ascites, and peri- 
toneal carcinoma — conditions which make radical operation illu- 
sory. When an early diagnosis has been made, it is inadvisable to 
delay operation, for, aside from favourable local conditions, resec- 
tion of the intestine requires endurance and strength on the part 
of the patient. Unfortunately, the absence of these qualities fre- 
quently renders radical operation impossible. 

The second indication for operation is increasing stenosis. In 
these cases a radical operation cannot be performed, either because 
adhesions make the removal of the tumour very difficult, or metas- 
tases are already present, or the weakened condition of the patient 
does not allow of a severe operation. In cancer of the small intes- 
tine gastro-enterostomy or entero-anastomosis comes in question ; 
in cancer of the large intestine (including the sigmoid flexure), 
entero-anastomosis or colostomy ; while in cancer of the rectum 
only colostomy. In rectal cancer some surgeons advise scraping or 
electrolytic removal of the stenosing tumour masses, but others of 
experience (among them Kraske and Czerny) advise against such 
procedures. 

When there is danger of intestinal obstruction or when it is 
already present, enterostomy or colostomy is generally indicated. 

Finally, regarding extirpation of rectal cancer, the indications to 
operate are influenced more by the mobility of the tumour than by 
its extent. In many cases examination under narcosis is necessary 
to decide the question of operability and the character of the sur- 
gical procedure to be used. In all obscure cases it is best for the 
medical practitioner and surgeon to consult, and together determine 
the mode of operation. 

The experienced medical practitioner can generally recognise 
inoperable cases of cancer of the rectum ; the extensive, rigid, fis- 
sured, ulcerated, absolutely immovable neoplasm leaves no room for 
indecision. In these cases we must decide whether a colostomy is 



INTESTINAL NEOPLASMS 361 

to be performed, or whether the patients are to be left to their 
fate. The decision is by no means an easy one ; each individual 
case must be carefully considered, not only respecting the condition 
of the rectum, but also the personality of the individual. Consid- 
ering the unfavourable cosmetic result, some surgeons strongly 
advise against colostomy, and only resort to the operation when an 
almost complete stenosis is present. 

Kraske 9 says : " It is horrible, even for a person of phlegmatic 
temperament, to witness daily the misery caused by the involuntary 
evacuation of faeces, and to know besides that a progressive and 
fatal disease is present." Frequently, however, patients are satis- 
fied with their condition after operation. 

II. Sarcoma and Lymphosarcoma of the Intestine 

According to Kundrat *, the best authority on these neoplasms, 
sarcoma and lymphosarcoma belong to the rarer intestinal tumours. 
Out of the large material of the Yienna General Hospital, he could 
collect only 3 sarcomata and 9 lymphosarcomata of the intestine 
between the years 1882 and 1893. 

Regarding the localization of sarcoma, Nothnagel * voices the 
general opinion when he states that the majority of cases are found 
in the small intestine, and only extremely rarely are they in the 
large intestine.f This view is correct if we exclude the rectum, 
where sarcomata are found as frequently as in the upper part of 
the intestinal canal. This conclusion is drawn from the careful 
work of Fr. Kriiger 59 , who has tabulated all the known cases of 
intestinal sarcoma reported up to the year 1894 — altogether 37. 
These tumours were distributed as follows : 

Small intestine 16 

Ileum and caecum 1 

Cecum 1 (2) J 

Vermiform appendix 1 

Transverse colon . 1 

Small and large intestine 1 

Rectum 16 

* Loc. cit., p. 250. 

f [Libman, American Journal of the Medical Sciences, September, 1900, p. 309, 
publishes an interesting report of four cases with detailed discussion of the clinical 
and histological aspects of sarcoma of the small intestine, together with an exten- 
sive reference to the literature of the subject. — Tr.] 

X A case reported by Carrington (cited by Baltzer, Archiv fur klin. Chir., vol. 
xliv, p. 744) has here escaped notice. 



362 DISEASES OF THE INTESTINES 

The ages of the patients were as follows : 

3 cases in the first decade. 



3 


a 


a 


second 


u 


6 


a 


a 


third 


u 


10 


a 


a 


fourth 


u 


5 


a 


a 


fifth 


a 


6 


u 


a 


sixth 


a 


4 


u 


a 


seventh 


a 



If we may judge from these rather few statistics, we see 
that the first decades by no means furnish so large a majority 
of the cases as is commonly believed. Furthermore, in contrast 
to cancer, the proportion of the male and female cases is strikiug 
(31 : 6). 

Eegarding the type of intestinal sarcoma, all possible forms 
may be observed — hard and soft, small and large spindle-celled, 
small and large round-celled, alveolar and medullary, melano- and 
cystosarcoma (Kriiger). The round- and spindle-celled forms* 
are the most frequent. They generally originate in the submucosa, 
extending inwardly to the tunica propria and outwardly to the mus- 
cularis. Some forms originate in the subserosa, and spread inwardly 
from here. 

The sarcomatous tumour is usually smooth and its size varies. 
It is often enormous. At different places it presents softened 
areas. It is not particularly painful, is frequently movable, and, in 
contrast to cancer, is distinguished by its rapid growth. 

Lymphosarcomata probably originate from the lymphatic sys- 
tem of the intestines. As already indicated by the difference of 
their development, the changes produced in the intestinal canal by 
sarcomata and lymphosarcomata are quite different from those of 
cancer. 

In cancer there is a circular, relatively well-defined area of dis- 
ease ; in sarcoma and lymphosarcoma the affected area is extensive 
and indefinite. As a result of this circular form of the cancerous 
tumour a stenosis results. In sarcoma, however, as pointed out by 
Treves, and later also by Baltzer 60 and Madelung 61 , there is almost 
always more or less demonstrable stretching and dilatation of the 
intestinal lumen. As demonstrated by Bessel-Hagen 62 in a case he 

* For further histological details I would refer to the text-books on pathological 
anatomy ; also particularly to the article by Ackermann, Die Histogenesis und His- 
tologie der Sarcome, Volkmann's Samml. klin. Vortrage, pp. 233, 234. 



INTESTINAL NEOPLASMS 363 

reported, the dilatation may become enormous. Sarcoma is much 
more apt to form metastases than is cancer, but, on the whole, this 
occurs late in the disease. Lymphosarcoma, on the other hand, 
seems to attack only the surrounding lymph glands. 

The question of the relation between tuberculosis and lympho- 
sarcomata is a peculiar one and has recently caused lively discussion. 
The observations of A. Miiller 63 , Claus 64 , Kicker 65 , Nothnagel,* 
Dietrich 66 , and Rud. Schmidt 67 , point to the possible coincidence of 
tuberculosis and lymphosarcomatosis. 

Hereditary tuberculosis is sometimes found in the family his- 
tory. A direct connection between the two diseases seems to be 
excluded ; still there is much in favour of the theory advanced, par- 
ticularly by Rudolf Schmidt, that there probably exist hereditary 
constitutional tendencies — that is, a sort of lessened power of resist- 
ance of the entire lymphatic system. 

The duration of intestinal sarcoma is shorter than that of can- 
cer ; most patients die within one year of cachexia, metastases, etc. 

Symptomatology, Diagnosis, and Differential Diagnosis 

The subjective symptoms of sarcoma of the small intestine pre- 
sent but few characteristic features. They consist in diffuse ab- 
dominal pain, nausea, vomiting (oftentimes said to be bilious m 
character), and marked irregularity of the bowels — obstinate consti- 
pation alternating with profuse diarrhoea. Where constipation 
alone was present, complications were always found (invagination 
or intestinal displacements). The most important objective symp- 
toms are the tumour, intestinal symptoms, and rapidly developed 
debility. In contrast to cancer the tumour is smooth, and often 
softened areas are to be felt ; it is well defined and easily mova- 
ble. Several cases have been reported (Made-lung) in which there 
was evident growth of the tumour within a few days. 

As is apparent from the above, the absence of the symptoms of 
stenosis is a characteristic of great diagnostic importance ; visible 
intestinal peristalsis and intestinal impactions are also absent. On 
the other hand, the extensive growth of the sarcoma may cause 
severe intestinal paralysis. 

To judge from a review of the histories of reported cases, the 
absence of intestinal hemorrhage is of some diagnostic significance, 
since this symptom is rather frequent in cancer. The very rapidly 

*Loc. cit., p. 253. 



364: DISEASES OF THE INTESTINES 

developed cachexia is a striking symptom ; it may become extreme 
within a few weeks or months. 

Other symptoms of possible diagnostic value are temporary 
oedema of the ankles, the early occurrence of ascites, and occa- 
sionally an irregular fever (up to 39.5° C. in a case of Madelung's). 
I find oedema of the ankles mentioned as a symptom in six of 
Kruger's 59 cases. 

The recognition of lymphosarcoma is very difficult, for, as 
shown by a study of the cases published, its symptoms may be 
quite different from those of sarcoma. Two examples of this are 
reported from Neusser's clinic in the above-mentioned work of 
Rudolf Schmidt 67 . Despite the greatest care, a correct diagnosis 
was not made. It is worthy of note that in the first of these two 
patients attacks of painful colic, inaugurated by distressing intestinal 
contraction and very loud borborygmi, were present. The diag- 
nosis lay between intestinal sarcoma and cancer. The autopsy 
showed a stenosis, which, however, was not produced by the neo- 
plasm, but by adhesions of two sarcomatous degenerated coils of 
intestine. In the second case, complicated by tuberculosis of the 
pulmonary apices, the clinical picture was that of peritoneal tuber- 
culosis. (Edema was present in both instances. 

Naturally the presence of a tumour is indispensable for the 
diagnosis ; a tumour in the second case might have made diagnosis 
possible. The above coincidence of pulmonary tuberculosis and 
lymphosarcoma shows the importance of a careful history. "When 
a characteristic tumour is present, the diagnosis of sarcoma of the 
small intestine presents no insurmountable difficulties, particu- 
larly when the age, rapid development, and absence of stenotic 
symptoms are taken into consideration.* When a well-defined 
tumour is absent a correct diagnosis is only accidental, although 
the course of the disease may justify the diagnosis of a malignant 
affection. 

When tuberculosis is present or suspected, particularly when 

* [Even in a young person presenting a tumour the diagnosis is by no means 
always possible. Two of Libman's cases (loc. cit.) very closely simulated appendi- 
citis. In the one, M. G., age 18 years, there was a history of only one day's stand- 
ing, with such acute symptoms that the case was thought to be a perforated appen- 
dicitis. In a third case the diagnosis lay between sarcoma of the kidney, tubercu- 
lar peritonitis, and sarcoma of the peritoneum, with possible primary tumour of 
the intestine. It must be remembered, too, that cancer of the intestine is by no 
means rarely met with in young individuals (see p. 297). — Tr.] 



INTESTINAL NEOPLASMS 365 

a serous effusion is present, the diagnosis will often lie between 
peritoneal tuberculosis and an obscure abdominal tumour (cancer, 
sarcoma, lymphosarcoma). The coincidence of tuberculosis and 
lymphosarcoma has already been mentioned. 

Treatment 

The treatment of intestinal sarcoma and lymphosarcoma is 
not different from that of cancer ; we therefore refer to the sec- 
tion on the therapy of intestinal cancer. Occasionally special symp- 
toms (e. g., diarrhoea) require treatment other than that given under 
cancer. 

As shown by the observations of Michel 68 , Gilford 69 , Hahn 40 , 
Engstrom 70 , and others, surgical treatment may at times be suc- 
cessful, even though the sarcoma be situated in the upper seg- 
ments of the intestinal canal. Favourable results are, however, 
much more frequent in sarcoma of the rectum. Recurrences 
generally occur sooner and more extensively than in intestinal 
cancer. 

"Where operation is contraindicated, the systematic subcutaneous 
injections of arsenic, according to the method of von Ziemssen 71 , 
have given favourable results both upon the symptoms and the 
general condition of the patient. 

B. BENIGN NEOPLASMS OF THE INTESTINAL CANAL 

Benign tumours of the intestine are extremely rare. Some 
possess no clinical interest, since they produce no symptoms during 
life. Others, however, are of greater importance from a diagnos- 
tic, therapeutic, and especially from a prognostic standpoint. It 
thus becomes necessary to describe these tumours. 

Benign intestinal neoplasms include adenoma, lipoma, fibroma, 
myoma, and myxoma. In some cases we have mixed tumours ; 
sometimes there are combinations of malignant and benign tumours 
(myosarcoma, fibro-sarcoma, myxosarcoma, adeno-carcinoma, etc.). 

I. Adenomata and Polypi 

The adenomata generally originate in the glands of Lieberkuhn 
and have a glandular structure. They occur on the mucous mem- 
brane either as sessile or pedunculated growths (polypi) ; they may 
be either isolated or multiple ; their size varies from that of a pea 
to a fist. They are found in all parts of the intestinal canal, but 



366 DISEASES OF THE INTESTINES 

their favourite seat is the rectum. They occur at different ages, 
but the first years of life contribute by far the largest number 
of examples. In some cases these polypi are the starting points 
for the development of malignant growths (sarcoma and cancer). 
Their transition into tuberculosis has been described by Prochow- 
nick 72 . 

Multiple polypi of the rectum and large intestine present a par- 
ticularly important type of adenomata. According to the observa- 
tions of Luschka 73 , Whitehead 74 , Hauser 75 , Schwab 76 , Port 77 , Holt- 
mann 78 , and others, they form tumours of various sizes which some- 
times extend along the entire length of the large intestine from 
the rectum to the iieo-csecal valve. Hauser and Port have shown 
that they may even extend into the small intestine and the pyloric 
orifice of the stomach. The interest in these cases lies particularly 
in the severe bleedings which they cause, and in their tendency to 
carcinomatous degeneration (Helferich — Port 77 , Bardenheuer 79 , 
Smith 80 , Handford 81 , Paget 82 , Hutchinson 82 , Makins 82 , Hauser 75 , 
Holtmann 78 ). A very striking fact is a certain hereditary predispo- 
sition, which was observed in no less than 4 of the 13 cases gathered 
by Port. In view of the relatively small number of these cases, 
I deem it proper to report one which I had under observation 
several years ago. 

Polyposis recti et coli ; partial extirpation of the polypoid masses ; death from 
peritonitis. 

Mrs. P. G-., age 36, working woman. As a girl the patient suffered from 
malaria, pneumonia, and pleurisy. Has had five children ; severe metrorrha- 
gia with the last. The beginning of the present illness dates back seven or eight 
years. She then complained of marked tenesmus, and even then the stools 
were always bloody. These symptoms ceased for months, during which time 
she felt well. The periods of remission became shorter from year to year, and 
latterly her symptoms have remained constant. 

Patient has about 20 evacuations a day, which are passed as follows : First, 
"bloody water " with mucus is passed ; then normal, thin, or semisolid faeces ; 
finally, often a large quantity of blood mixed with mucus. At times there are 
absolutely no faeces in the evacuations. For several years, at the end of each 
evacuation a nodule was protruded from the anus ; this finally fell off ; it 
looked "as if composed of small growths." After this patient felt better 
for a few days, except for the tenesmus and the hemorrhages. The general 
condition of the patient is only very slightly disturbed. 

Status Prmens. — Anaemic woman ; normal circulatory and respiratory organs ; 
ptosis and atony of the stomach ; displaced right kidney ; no other abdominal 
irregularity on palpation ; intestines not sensitive to pressure. On rectal 
examination there were found grapelike masses as large as peas or beans, which 



INTESTINAL NEOPLASMS 



367 



consisted of broad-based excrescences ; about 20 of these were easily removed 
by the examining finger. After rectal lavage, blood and several pea-sized 
polypi were found in the wash water. Microscopical examination shows dis- 
tinct adenomatous structure. Upon severe straining a deep-red tumour, about 
the size of an ostrich egg, protruded itself. It consisted of numerous large 
and small polypi, and of several hemorrhoidal nodules. 

Since extirpation (see Fig. 30) of the rectum seemed impossible, the mass 
was partially removed on July 25, 1893. During the operation the peritoneum 
was opened. Death from peritonitis three days later. Autopsy showed that 
the entire length of the large intestine was carpeted, as it were, with innu- 
merable large and small polypi. 

Adenomata, particularly of the rectum, are easily diagnosti- 
cated, especially, when the protrusion of one or two polypi, as so 
frequently happens, allows of a direct 
macroscopic and microscopic examina- 
tion. 

Of the subjective symptoms hemor- 
rhage and tenesmus particularly neces- 
sitate a digital examination. If the 
patient strains during such examina- 
tion, the finger may draw down a sin- 
gle or more often multiple polypi out 
of the anus ; these may then be care- 
fully tied and cut off and their struc- 
ture immediately studied. 

Even when the tumours are situated 
higher up, their recognition is not very 
difficult ; the soft consistency, the well- 
defined limits, the pedicle, the absence 
of ulcerations, particularly the sharp 
localization of the process, are unmis- 
takable. However, the fact that ma- 
lignant processes may develop upon the 
bases of such polypoid growths, of 
which I myself have observed two in- 
stances, must warn the physician to be guarded in the prognosis. 
If multiple rectal polypi are present we must suspect further exten- 
sion of the growths into the intestinal canal. 




Fig. 30.— Multiple Polypi of the 
Eectum. (Personal observation.) 



II. Lipoma, Myoma 

Lipoma is more frequent than myoma. There are scarcely two 
dozen clinically observed cases of myoma, but since the advance of 



368 DISEASES OF THE INTESTINES 

surgery the cases of intestinal myoma reported seem to have mate- 
rially increased. The remaining benign intestinal tumours (angi- 
oma, myxoma, teratoma, and others) possess as yet no clinical sig- 
nificance. 

Lipomata generally originate in the submucosa, their most fre- 
quent seat being the large intestine and rectum. Their size varies 
considerably; generally, however, they are of an appreciable size 
(up to that of a child's head). They occur either isolated or mul- 
tiple. The diagnosis of lipoma is only possible when they are situ- 
ated in the rectum and produce symptoms. In other cases where 
no tumour is felt either by vaginal or abdominal examination, a 
definite diagnosis is impossible. Occasionally expulsion of the 
lipoma (Castelain ^ Albrecht 84 , Link 85 , Paci 86 , etc.) has revealed 
the cause of the symptoms. 

Myomata of the intestinal canal arise partly from the mucosa 
and submucosa, partly from the subserosa. Following Yirchow, 
those from the mucosa and submucosa are known as internal, and 
those from the subserosa as external myomata. Stein er 87 , who has 
made an exhaustive analysis of benign neoplasms of the gastro- 
intestinal canal, reported 19 cases of internal and 15 of external 
myomata. The tumour is usually situated in the small intestine, 
and only exceptionally in the large intestine (inclusive of the rec- 
tum). The duodenum is very rarely affected. Myomata vary 
very much in size ; they may be as small as cherries or as large as 
a man's head. As regards the age at which myomata may occur, 
they are by no means limited to young individuals ; cases have 
been reported in persons forty, fifty, and even eighty years of age. 

Only when there is a definite tumour can the symptomatology 
and diagnosis of myomata be considered. Such palpable tumours 
are found in but a limited number of cases, but even then the 
diagnosis will be made in very exceptional instances. The diagnosis 
will be possible in internal myomata, when certain complemental 
symptoms or complications which tend to clear up the clinical pic- 
ture are present. Among these we might mention the develop- 
ment of a more or less complete invagination, which, according to 
Steiner, was observed no less than 7 times in 18 cases. In a case of 
this nature described by Fleiner 88 , in view of the chronic course of 
the disease, of the variation of the patient's condition from good to 
bad, etc., the diagnosis of myoma was made with a fair degree of 
probability. Besides an invagination, the gradual development of 
an intestinal stenosis or an obstruction is of great diagnostic signifi- 



INTESTINAL NEOPLASMS 369 

cance ; in such cases, days, weeks, months, or even years of abso- 
lutely good health may intervene. 

The symptoms of external myomata are only rarely sharply 
defined. Evidences of stenosis may be present, thus making the 
connection between the neoplasm and the intestinal canal more 
probable. Complete obstruction by kinking, incarcerations, or 
volvulus, appears to be still more infrequent. In several in- 
stances the intestinal contents were bloody, and contained much 
mucus. Death from profuse hemorrhages from the bowel has also 
been described. 

According to Steiner 87 the following data indicate external 
myomata : The presence of a slowly growing, intraperitoneal (some- 
times also retroperitoneal) tumour, hard and nodular on its sur- 
face, and having no connection with the genital organs ; passive 
movements of this tumour cause dragging pain in the abdomen ; 
there may be symptoms of an obstruction of the intestinal lumen, 
and finally intestinal hemorrhages. 

Despite these data we shall hardly be able to diagnosticate other 
than the presence of an intestinal neoplasm of unknown nature. 

Myomata of the rectum require a brief mention. According 
to Steiner, only 6 cases have been observed. Here also we dis- 
tinguish between the external and internal myomata. The symp- 
tomatology of the latter is quite similar to that of pedunculated 
polypi — passing of blood and mucus, tenesmus, and, when of large 
size, evidences of rectal stricture. The diagnosis of myoma recti 
may be made when by rectal (and vaginal) examination a rather 
smooth, movable tumour, with a more or less thick pedicle attached 
to the mucous membrane is felt. 

The clinical picture of external rectal myomata is much less 
characteristic. When they reach considerable size they compress 
the pelvic organs and become adherent to the latter. The only re- 
maining diagnostic data are the occurrence of rectal hemorrhages 
and the obstruction to evacuations. It would also be of diagnostic 
importance to demonstrate that the tumour is not connected with 
the genital organs. 

Treatment 

!No matter in what portion of the intestinal canal the benign 
tumour may be found, internal treatment can be of little benefit. 
We shall have to limit ourselves to the treatment of the symptoms 
— pain, stenosis, enterorrhagia, etc. 



370 DISEASES OF THE INTESTINES 

Expectant treatment may be successful, for benign tumours, 
especially when situated in the lower intestinal segments, are some- 
times spontaneously expelled. As already mentioned, this has been 
observed in lipomata, adenomata (polypi), and myomata (Pellizari 89 , 
Heurteux 90 ). 

Regarding simple pedunculated polypi of the rectum, their 
removal is easily accomplished with the scissors or the galvano- 
cautery. The case is quite different, however, with larger myom- 
ata of the intestinal canal. In many cases we shall have to be 
content with palliative treatment. Should dangerous symptoms 
occur (invagination, complete or beginning intestinal obstruction, 
severe, repeated intestinal hemorrhages), operative extirpation of the 
tumour is indicated. Successful operative results in internal my- 
omata have been reported by Fleiner, Czerny, Lockwood, Albert, 
Rosi, Fenger, and Hollander 91 . External myomata have also been 
successfully operated on (Wolfler, Babes-Nanu, Kukula, and Kru- 
kenberg). 

Internal rectal myomata offer no great difficulties to surgical 
treatment, for ligation of the pedicle and removal of the tumour is 
usually sufficient. The treatment of external myomata of the 
rectum is the same as that of rectal cancer. Removal of the 
tumour by laparotomy is indicated when its growth extends beyond 
the small pelvis. Cure resulted in 3 out of 4 cases of external rec- 
tal myoma (Berg, Senn, Pfannenstiel 92 ). 

General intestinal polyposis is not favourable either for internal 
or surgical treatment. Our therapeutic aim will be limited to 
decreasing the hemorrhages by appropriate internal medication 
(ergotin, hydrastin, witch-hazel), or by astringent enemata (fer- 
ripyrin, tannin, aceto-tartrate of aluminum). Partial extirpation 
of the growth may be symptomatically advantageous. Thus, in a 
case of polyposis of the jejunum and ileum recently reported by 
von Karajan 93 , complete cure resulted from extirpation of 10 of the 
largest polypi. In a case reported by Sklif assowski u , the forma- 
tion of an artificial anus seemed to have been followed by some 
benefit. 

LITERATURE 

1. A. Zemann. Bibliothek d. medicin. Wissenschaften (Drasche), Bd. iii, H. 

1 u. 2, S. 49. 

2. G. Heimann. Archiv f. klin. Chirurgie, 1899, Bd. lvii, H. 4. 

3. Berard, Rokitansky. Cited from Leube in v. Ziemssen's Handbook, p. 

335, vol. vii, Part II, second edition. 



INTESTINAL NEOPLASMS 371 

4. P. Rtipp. Ueber den Darmkrebs mit Ausschluss d. Mastdarmkrebses. 

Inaug.-Diss., Zurich, 1894, S. 10. 

5. Maydl. Ueber den Darmkrebs. Wien, 1883, S. 10. 

6. Nothnagel. Darmerkrankungen, S. 219. 

7. Hausmann. These de Paris, 1882. 

8. Iversen. Yerhandl. des X. internationalen medicinischen Congresses, Ber- 

lin, 1891, Bd. iii, S. 98. 

9. Kraske. Erfahrungen tiber den Mastdarmkrebs. Volkmann's Saminlung 

klinischer Yortrage, 1883, 1884, 1897, S. 787. 

10. Kast u. Baas. Munch, med. Wochenschr., 1888, No. 4. 

11. Rommelare. Journ. de med., de chirurgie, et de pharmacie de Bruxelles, 

1883-1886. 

12. Fr. Miiller. Zeitschr. f. klin. Medicin, Bd. xvi, S. 146. 

13. G. Klemperer. Berl. klin. Wochenschr., 1889, No. 40. 

14. Schneyer. Internat. klinische Rundschau, 1894, No. 39. 

15. F. Henry. Arch, fur Verdauungskrankheiten, 1898, Bd. iv, H. 1. 

16. Czygan. Ibid, 1897, Bd. iii, S. 82. 

17. Leichtenstern. von Ziemssen's Handbuch, 1878, Bd. vii, 2, 2te Aufl., S. 

418. 

18. Herz. Deutsche med. Wochenschr., 1896, No. 23 u. 24. 

19. Gerhardi. Yirchow's Archiv, 1886, Bd. cvi, S. 303. Inaug.-Diss., Zurich, 

1886. 

20. Hagenbach. Deutsche Zeitschr. f. Chirurgie, 1887, Bd. xxvii, H. 1 u. 2, 

S. 110. 

21. Wilms. Beitrage zur klin. Chirurgie, 1897, Bd. xviii, H. 2. 

22. Weecke. Inaug.-Diss., Kiel, 1894. 

23. Pic. Revue de medecine, 1894, No. 12, and 1895, No. 1. 

24. Bard et Pic. Ibid., 1888, vol. viii. 

25. Lannois et Courmont. Ibid., 1894, vol. xiv. 

26. Janicke. Wiirzburger Verhandlungen, 1877. 

27. Kernig. Petersburger med. Wochenschr., 1881, No. 4. 

28. Oser. Die Erkrankungen des Pankreas, Wien, 1898, S. 214. 

29. Mirallie. Gaz. des hopitaux, 1893, p. 889. 

30. Treves. Darmobstruction. Uebersetzt von A. Pollak, 1888. [Intestinal 

Obstructions. New York, 1899.] 

31. Potain. Cited from Maydl, Ueber den Darmkrebs, 1883, S. 51. 

32. Wunderlich. Cited from Riipp (see ref. 4). 

33. Nicolaysen. Cited from Maydl (see ref. 5). 

34. Bamberger. Krankheiten des Chylopoetischen Systems. Yirchow's Handb. 

d. spec. Pathologie u. Therapie, Bd. vi, Wurzburg, 1864. 

35. Bamberger. Zeitschr. f. prakt. Heilkunde, 1857, Bd. iii. 

36. Krausshold. Ueber Krankheiten des Proc. vermiformes u. des Coecums. 

Yolkmann's Sammlung klin. Yortrage, No. 191. 

37. Schede. Cited from Paul Wolff, Ueber Geschwiilste d. Ileocoecalgegend. 

Inaug.-Diss., Berlin, 1893. 

38. Richelot u. Hartmann. Cited from Yirchow-Hirsch's Jahresbericht, 1894, 

Th. ii, S. 462. 

39. von Bergmann. Deutsche med. Wochenschr., 1895, Yereinsbl., S. 54. 



372 DISEASES OF THE INTESTINES 

40. Halm. Berl. klin. Wochenschr. , 1887, No. 25. 

41. Czerny. Beitrage zur klin. Chirurgie, Bd. ix, S. 797, Fall 14. 

42. von Esmarch. Cited from J. Mockenhaupt. Inaug.-Diss., Kiel, 1894. 

43. Salzer. Arch. f. klin. Chirurgie, Bd. xliii, S. 149. 

44. Passler. Berl. klin. Wochenschr., 1895, No. 34. 

45. Israel. Ibid., 1894, No. 11. 

46. Hochenegg. Wiener klin. Wochenschr., 1897, No. 32. 

47. Wolfler. Berl. klin. Wochenschr., 1896, No. 24. 

48. Billroth. Yerhandlungen des X. internationalen Congresses zu Berlin, 

1891, Bd. iii, Abth. 7, S. 76 u. f. 

49. Czerny. XII. Chirurgencongress, 1893. 

50. Nicolaysen. Cited from Ktipp (see ref. 4). 

51. Hochenegg. Wiener klin. Wochenschr., 1888, No. 14-16, 1889, No. 

26-30. 

52. von Heinecke. Munch, med. Wochenschr., 1888, No. 35. 

53. W. Levy. Centralbl. f. Chirurgie, 1889, No. 13. 

54. Schlange. Berl. klin. Wochenschr., 1892, No. 47. 

55. Liermann. Beitrage zur klin. Chirurgie, Bd. xix, H. 3, and Arch. f. klin. 

Chirurgie, Bd. lviii, H. 2. ' 

56. Lovinsohn. Beitrage zur klin. Chirurgie, Bd. x, S. 208. Lobstein. Berl. 

klin. Wochenschr., 1897, No. 30 u. 31. 

57. Czerny. Berl. klin. Wochenschr., 1897, No. 36. 

58. Kundrat. Wiener klin. Wochenschr., 1893, No. 12. 

59. Fr. Kriiger. Inaug.-Diss., Berlin, 1894. 

60. Baltzer. Arch. f. klin. Chirurgie, Bd. xliv, H. 4. 

61. Madelung. Centralbl. f. Chirurgie, 1892, No. 30. 

62. Bessel-Hagen. Virchow's Archiv, Bd. xcix, S. 99. 

63. Mtiller. Inaug.-Diss., Zurich, 1894. 

64. W. Claus. Inaug.-Diss., 1888. 

65. Ricker. Arch. f. klin. Chirurgie, 1895, Bd. 1. 

66. Dietrich. Beitrage zur klin. Chirurgie, 1896, S. 377. 

67. Rud. Schmidt. Wiener klin. Wochenschr., 1898, No. 21. 

68. Michel. Inaug.-Diss., Wurzburg, 1889. 

69. Gilford. The Lancet, 1889, 1893. 

70. Engstrom. Cited from Arch. f. Yerdauungskrankheiten, vol. iv, p. 219. 

71. von Ziemssen. Deutsches Arch. f. klin. Medicin, 1895, Bd. lvi, H. 1 u. 2, 

S. 124. 

72. Prochownick. Munch, med. Wochenschr., 1896, No. 49. 

73. Luschka. Virchow's Archiv, Bd. xx, S. 133. 

74. Whitehead. Brit. Med. Journal, p. 410, 1884. 

75. Hauser. Deutsches Arch. f. klin. Medicin, Bd. Iv, S. 429, and Das 

Cylinderepithelcarcinom d. Magens u. d. Dickdarms, Jena, 1890, S. 
182 u. 191. 

76. Schwab. Beitrage zur klin. Chirurgie, Bd. xviii. 

77. Port. Zeitschr. f. Chirurgie, Bd. xlii, H. 1 u. 2. 

78. Holtmann. Multiple Polypen des Colon mit Gallertkrebs. Inaug.-Diss., 

Kiel, 1895. 

79. Bardenheuer. Arch. f. klin. Chirurgie, Bd. xli, H. 4. 



INTESTINAL NEOPLASMS 373 

80. Smith. St. Barthol. Hosp. Rep., vol. xxiii, 1887. 

81. Handford. Transact, of the Pathol. Soc. of London, vol. xli, 1890. 

82. Paget, Hutchison, and Makius. Cited from Port (see ref. 77). 

83. Castelain. Gaz. hebdom. de medecine et de Chirurg., 1870, No. 20. 

84. Albrecht. St. Petersburger med. Wochenschr., 1880, No. 9. 

85. Link. Wiener klin. Wochenschr., 1882, S. 247. 

86. Paci. Le Sperimentale, 1882, p. 46. (Cited from Virchow-Hirsch's Jahres- 

bericht, 1882.) 

87. Steiner. Beitrage zur klin. Chirurgie, 1898, Bd. xxii, H. 1 u. 2. (Here 

will be found extensive literary references.) 

88. Fleiner. Virchow's Archiv, 1885, Bd. ci, S. 484 u. f. 

89. Pellizari. Societa medico-fisica florentina, 1874. (Cited from Steiner, 

ref. 87.) 

90. Heurteux. Gaz. medic, de Nantes, 1884, p. 135. (Cited from Steiner, ref. 

87.) 

91. Hollander. Cited from Steiner (ref. 87). 

92. Pfannenstiel. Allgemeine medicin. Centralzeitung, 1897, S. 56. 

93. von Karajan. Wiener klin. Wochenschr., 1899, No. 6. 

94. Sklifassowski. Wratsch, 1881, No. 4. (Cited from Centralbl. f. Chirurgie, 

1881, S. 527.) 



25 



CHAPTEE XIX 

ACTINOMYCOSIS OF THE INTESTINES 

Definition. — An infection of the intestinal tract with the acti- 
nomyces hominis or ray fungi. 

Intestinal actinomycosis may occur as a secondary manifesta- 
tion, either by extension, or through a metastasis by means of the 
blood-vessels of actinomycosis in some other part of the body; or 
what is more rare, as a primary disease. 

J. Israel 1 classifies actinomycosis according to the point of 
entrance of the infection as oral or pharyngeal, primary pul- 
monary, primary intestinal, of uncertain origin and cutaneous. 
The comparative frequency of these various forms can be seen 
from the statistics of Illich. 2 In 421 cases collected by him, in- 
cluding 54 personal observations in Albert's clinic, he found the 
head and neck affected 218 times, the tongue 16 times, lungs 58 
times, abdomen 89 times, skin 11 times; 29 times the primary 
focus could not be determined. 

Etiology. — It is probable that the infection occurs through 
the gastro-intestinal tract, although the mode of entrance of the 
fungus has not as yet been learned. That the ingestion of meat or 
milk of actinomycotic cattle can produce the disease is extremely 
doubtful. 

Varieties. — The only instance of the superficial form of the dis- 
ease on record is the case of Chiari. 3 The patient, who was suf- 
fering from dementia paralytica, presented the symptoms of dys- 
entery; the diagnosis was first made at autopsy. In all the other 
known cases the entire thickness of the intestine was invaded. 

Pathology. — Any part of the intestinal tract may be affected; 
it is even possible that the disease may occur in the stomach 
(Israel 4 ). Diminished peristalsis seems to favour the localization 
of the actinomyses (F. v. Koranyi 5 ). Thus Lanz 6 found that 
the cecum and appendix ("perityphlitis actinomycotica ") were 
affected in 50 per cent, of the cases, whereas the adjoining por- 
tions of the large and small intestines were only rarely the pri- 
374 



ACTINOMYCOSIS OF THE INTESTINES 375 

mary site of the disease. In the remaining 50 per cent, of the 
cases the disease was localized either in the small or large intes- 
tines, colon, rectum and stomach. 

The ray fungus sets up a circumscribed (occasionally a more 
extensive) irritation of the intestinal mucosa. The inflammation 
and infiltration of the actinomyses extend gradually towards the 
peritoneal coat, and give rise either to a chronic peritonitis or an 
acute peritonitis with a serous or even purulent exudate. The 
infection may extend to adjacent viscera, the extraperitoneal cel- 
lular tissue, the abdominal wall or the soft or bony pelvis. Throm- 
bosis and embolism by means of the portal vein (more rarely 
through the arteries) may occur. 

Symptoms. — The initial symptoms of the disease are vague 
and consist of pain and disturbance of the function of the in- 
testines. Paroxysmal pains of a colicky nature are experienced, 
associated with a more or less pronounced diarrhoea or obstipa- 
tion. The pain is not always sharply localized in one part of the 
abdomen, although it may be first experienced as an obstinate 
pain in one side. 

Cases of " perityphlitis actinomycotica " present the clinical 
picture of an acute, chronic or recurring appendicitis, with the 
formation of a large indurated tumour mass in the right iliac 
region, which shows a decided tendency to gravitate towards the 
pelvis. The diagnosis only becomes clear by finding the character- 
istic actinomyces granules in the pus of the abscess. Rectal acti- 
nomycosis runs its course either with dysenteric manifestations 
or as a periproctitis. 

By the extension of the process from the intestines to adjacent 
viscera and other tissues of the abdomen a great variety of symp- 
toms are produced. Thus we may find a perinephritis, a parame- 
tritis, a peripsoitis (preceded by flexion and oedema of the leg), 
etc. All cases have a tendency to extend to the abdominal wall 
and form hard, not sharply circumscribed, painful tumours, which 
soften and break down and gravitate either towards Poupart's lig- 
ament, the region of the rectum, or some point on the anterior sur- 
face of the lower part of the abdomen. According to l^othnagel 
this infiltration of the abdominal wall may be the first symptom. 
By the breaking down of the abscesses, fistulous tracts, which dis- 
charge a viscid, serous fluid containing broken-down tissue and 
actinomyces granules, are formed. 



376 DISEASES OF THE INTESTINES 

In affections of the lower bowel these granules are found in 
the stools. They were found in the urine in a case of Billroth's, 
where perforation of a rectal actinomycosis had occurred into the 
bladder. 

When the initial symptoms are slight they may be entirely 
overlooked, the involvement of the peritoneum first attracting at- 
tention to the disease. In these cases the clinical picture is that 
of an acute or chronic " tubercular " peritonitis. Infection with 
pyogenic cocci changes the entire symptomatology and overshad- 
ows the picture of the primary disease. 

Course. — The disease tends to run a chronic course, death gen- 
erally ensuing from exhaustion and cachexia. An acute fatal 
termination may occur, however, through intestinal perforation, 
the formation of multiple metastases or an intercurrent sepsis. 
Spontaneous cures are recorded as well as cures after compara- 
tively insignificant surgical procedures. In general, where the 
disease is not circumscribed and amenable to surgical interference 
by removal of the locus morbi, the prognosis is bad. 

Treatment. — When the diseased tissues cannot be removed, 
injections of corrosive sublimate (1:1000) or a 1 per cent, solu- 
tion of potassium iodid (Rydygier) are recommended. The latter 
drug has also been administered internally by Thomasen-!N"etter 
in doses of 6 to 90 gm. for a period of twenty-five days, with 
some interruption. Recurrences have also been noted after two 
years in cases apparently cured. 

LITERATURE 

1. J. Israel. Klin. Beitrage zur Kenntniss d. Actinomykose des Menschen. 

Berlin, 1885. 

2. Illich. Beitrag zur Klinik der Actinomykose. Wien, 1892. 

3. Chiari. Ueber primare Darmactinomykose beim Menschen. Prager med. 

Wochenschrift, 1884. 

4. J. Israel. Ein Fall von Bauchactinomykose. Deutsche med. Wochenschr., 

No. ix, 1889. 

5. F. v. Koranyi. Die Strahlenpilzkrankheit. Nothnagel, Spec. Pathologic 

u. Therapie, Bd. v, Th. 1. 

6. Lanz. Ueber Perityphlitis actinomycotica. Correspondenzblatt f . Schweizei 

Aerzte, 1888, No. 11 u. 12. 



CHAPTER XX 

SYPHILIS OF THE INTESTINES 

Excepting when localized in the rectum,* syphilis of the intes- 
tines has more of a pathological than a clinical interest and im- 
portance. This is due to the fact that the lesions are productive 
of no characteristic symptoms, and are almost invariably co-exist- 
ent with other phenomena of luetic infection. All authorities are 
agreed that syphilis of the intestines is very rare (Nothnagel, 1 
Ewald, 2 Orth, 3 Osier, 4 Birch-Hirschfeld, 5 Hemmeter, 6 etc.). It 
may involve the small or large intestine, the upper portion of 
the former, and more especially the jejunum is most frequently 
affected. 

Pathology. — Mracek, 7 who has studied the hereditary form of 
the disease with special care, states that there may be non-specific 
as well as specific lesions present. The former consists in an in- 
tense hyperemia of the mucous membrane, which, together with 
the submucosa, is the seat of a marked nuclear proliferation. The 
changes in the serous coat may be those of chronic inflammation 
(cloudy swelling, false membrane, adhesions, etc.), or there may 
be a production of a fibrinous or even purulent exudation. 

The specific changes in both the hereditary and the acquired 
form include plaques, neoplasms, and ulcers. While there is no 
reason to doubt their occurrence, mucous patches such as are ordi- 
narily observed as secondary manifestations in syphilis of other 
(orificial) mucous membranes have not been described in intes- 
tinal syphilis. At the autopsy of a syphilitic subject, Birch- 
Hirschfeld 5 found numerous sclerosed patches in the jejunum. 
They lay transversely to the axis of the bowel, extended to the sub- 
mucosa, and on microscopical examination showed all the features 
of broken-down gummata with sclerotic changes in the central 
portions. They were, no doubt, manifestations of the advanced 
stages of syphilis. 

* For Syphilis of the Rectum, see chapter xxiii. 

377 



378 DISEASES OF THE INTESTINES 

Two forms of neoplasms have been described, the diffused 
syphilomata and the gummata. The former are characterized by 
their profusion of spindle cells and appear as scattered nodules 
or as slightly raised and flattened growths. The gummata are 
always multiple and have been observed under two forms, the mil- 
iary and the large nodules. The miliary variety is more often asso- 
ciated with the hereditary form of syphilis. Gummata may origi- 
nate from the lymph glands of the mucous membrane, the solitary 
or agminated glands, or independently of any of these. Peyer's 
patches especially may degenerate into large flat gummata. The 
gummata are located for the most part in the submucosa, al- 
though Jiirgens, 8 perhaps alone, describes them as occurring 
mainly in the muscular layer. By confluence of two or more large 
gummata, tumours of quite some magnitude may be formed. 
These intestinal gummata in common with other syphilitic neo- 
plasms have an intimate association with the vascular system. 
The syphilitic growths begin about the arteries ; a proliferation of 
the arterial endothelium with occlusion of the lumen takes place, 
and in consequence of the resulting anaemia there is a retrograde 
metamorphosis of the gummata (Mracek 7 ). This retrograde met- 
amorphosis is quite characteristic of syphilitic neoplasm; it may 
be very minute but its presence robs the tissues of their staining 
properties. 

Ulcers result usually from the breaking down of the gummata. 
Their appearance, etc., has already been described on p. 266 of this 
work. Frequently there is an infiltration and a thickening of the 
serous coat corresponding with the situation of the ulcer. Klebs 9 
found a number of small, hard, fibrous nodules in the serous coat 
following the course of the lymphatics. The entire intestinal wall 
about the ulcer may be infiltrated, and where several large ulcers 
lie closely together, a considerable tumour may be formed. The 
retroperitoneal and mesenteric glands are frequently enlarged, 
forming palpable tumour masses. Several ulcers may coalesce, 
and after healing the cicatrix may contract and stenosis of the 
bowel result. 

Symptoms and Diagnosis. — There are no clinical signs that 
are pathognomonic of syphilis of the intestines. The phenomena 
which are observed will depend upon the variety and location of 
the lesion. There may be an entire absence # of all symptoms, or 
simply those of intestinal catarrh, ulceration, or neoplasm be pres- 



SYPHILIS OF THE INTESTINES 379 

ent. A detailed account of the manifestations of these lesions is 
given elsewhere in this work (see Index). The diagnosis of syphi- 
lis of the intestines will always necessitate the elicitation of a pre- 
vious history of infection or the existence of other signs of the dis- 
ease (eruption, condylomata, sore throat, gummata, bone lesions, 
etc.). In the absence of these a positive diagnosis is either alto- 
gether impossible or only possible ex juvantibus. In every case 
of chronic catarrh, ulcer or tumour of the intestine which proves 
refractory to ordinary methods, the possibility of a luetic basis 
must not be overlooked. 

Prognosis. — This will depend upon the proper recognition of 
the underlying disease, the nature of the lesion and the presence 
or absence of complications. Uncomplicated cases should yield to 
anti-syphilitic treatment, although it must be remembered that 
visceral syphilis is one of the most obstinate of the later manifes- 
tations of this disease. The presence of adhesions, stenoses, large 
tumours and other complications render the ultimate outcome more 
unfavourable. It must also be mentioned that not infrequently 
amyloid degeneration of the intestines appears as a late sequela of 
syphilis. 

Treatment. — On account of the refractory nature of visceral 
syphilis prolonged and repeated use of both iodids and mercurials 
will be required. The iodid should be rapidly increased to the 
point of toleration. ^Mercury should be preferably administered 
by injection or inunction. Mechanical obstructions from stenosis, 
bands, tumours, etc., will generally require surgical interference. 
(See Chaps. XYIII and XXI.) The special treatment of the more 
serious ulcers and tumours will be found elsewhere under the 
proper classification. 

LITERATURE 

1. Nothnagel. Die Erkrankungen d. Darms und d. Peritoneum. Wien. 1898, 

p. 167. 

2. Ewald. Klinik d. Verdauungskrankheiten. Berlin. 1903. p. 194. 

3. Orth. Lehrbuch d. spec, patholog. Anatomic Berlin, 1887, Bd. i, p. 842. 

4. Osier. Principles and Practice of Medicine. New York, 1903, p. 249. 

5. Birch-Hirschfeld. Lehrbuch d. patholog. Anatomic Leipsic, 1887. p. 589. 

6. Hemmeter. Diseases of the Intestines. Phila.. 1902. vol. ii, p. 101. 

7. Mracek. Vierteljahrschr. f. Dermatol, u. Syphil., 1880, Bd. x, p. 209. 

8. Jurgens. Berl. klin. Wochenschr., 1880, p. 677. 

9. Klebs. Handb. d. patholog. Anatomie, 1869, Bd. i. p. 261. 



CHAPTEK XXI 

INTESTINAL STENOSIS AND INTESTINAL OBSTRUCTION 

{ILEUS) 

A. INTESTINAL STENOSIS 

Preliminary JRemarhs. — Of all disturbances of the intestinal 
canal, the most serious are those which interfere with the normal 
passage of the faeces. Where they do not directly threaten life, 
such disturbances cause a number of extremely distressing symptoms, 
which, unless relieved, gradually undermine the constitution of the 
patient and finally produce death. At first, the variety and situa- 
tion of the obstruction seem of secondary importance to the dan- 
gers arising therefrom ; for, with the single exception of fsecal 
impaction, the danger in all varieties of intestinal obstruction is 
practically the same. It would thus seem that the trouble taken 
in the study and classification of the various forms of intestinal 
obstruction has but little practical value. A more detailed knowl- 
edge and more careful study will show that this idea is incorrect. 
The clinical features of intestinal obstruction are never the same, 
and the recognition of the differences in different cases is im- 
portant for diagnostic, prognostic, and therapeutic purposes, par- 
ticularly in surgery. There are only a few, though perhaps very 
important, varieties of intestinal obstruction which really offer in- 
surmountable diagnostic difficulties. 

In every case of intestinal obstruction the following facts must 
be determined before a diagnosis can be arrived at : 

1. First and most important, the establishment of the presence 
of intestinal obstruction or stenosis. 

2. Determination of its situation. 

3. Determination of its anatomical causes. 

In order to understand the symptoms of individual cases, and in 
view of the practical purpose of this work, it appears to me prefer- 
able to first give the general symptomatology of intestinal strictures 
and occlusions, and then the symptomatology and diagnosis of the 
several kinds of obstruction. The differential diagnosis will be 
380 d 



INTESTINAL STENOSIS 381 

treated of in a separate section, and, finally, the treatment of all 
forms will be discussed together. Owing to their extreme rarity 
and because of their lack of practical clinical significance, congenital 
stenosis and occlusion will be left entirely out of consideration. 
Stenoses of the rectum are described in the chapter on Diseases of 
the Rectum. 

General Symptomatology of Stricture of the Intestine 

The idea embodied in the term " intestinal stricture " already 
seems to imply a gradual development with well-defined symptoms 
only in advanced stages of the disease. Patients, as a rule, complain 
of the characteristic symptoms of stricture only when the process is 
relatively far advanced. There are, however, important exceptions 
to the usual course. In the first place, a chronic stricture may de- 
velop shortly after a complete obstruction (pseudo-ligaments, hernial 
orifices, partial obstruction by gallstones, foreign bodies, intestinal 
concretions, intussusception, compression) (Leichtenstern : ). On the 
other hand, the characteristic picture of chronic intestinal stenosis 
may for a time be present ; then, either through muscular paralysis, 
marked increase of the stricture, or through impaction of foreign 
bodies (generally undigested food), the chronic stenosis suddenly 
changes into a complete intestinal obstruction. In other cases, 
again, the change is less acute. For example, a patient has passed 
through several attacks of intestinal stenosis, each one more severe 
than the preceding one, so that it is probable that the next attack 
will be one of complete obstruction. 

The clinical picture varies in accordance with the site and de- 
gree of the stenosis. 

Regarding the site, we may, in general, differentiate between 
strictures of the upper and of the lower segments of the intestines, 
the former including the portions from below the pylorus to the 
jejunum inclusive, the latter those from the ileum to the rectum. 
Both have this in common, that the normal onward movement of the 
bowel contents is either delayed or entirely interfered with. As 
a natural result a dilatation gradually develops above the stenosis, 
and acts as a reservoir for the retained fluid or solid masses. It 
is quite evident that this will occur to a lesser degree in stenoses 
above the jejunum than in those lower down. It is clear that the 
latter variety demands considerably greater expulsive power of the 
intestinal muscles than does the former. Finally, in deep-seated 
stenoses the recoil contraction can have little effect in causing a 



382 DISEASES OF THE INTESTINES 

backward movement of the solid matters in the intestine ; in ste- 
noses of the npper bowel, however, where the contents are fluid, 
very little force is required for their regurgitation. 

From these differences the chief symptomatological distinctions 
between the two types arise. 

Let us begin with the small intestine. In general the symp- 
toms point rather to disturbances of gastric than of intestinal func- 
tions. The subjective symptoms are those of chronic overdisten- 
tion of the stomach from the backward pressure of the retained 
duodenal and jejunal contents — viz., fulness, pressure, pains, eruc- 
tation, nausea, vomiting. 

Naturally this permanent stasis is not without its effect upon 
the appetite and nutrition — both of these suffer more or less. The 
increasing vomiting will also affect or retard the evacuations, but 
not nearly as much as in stenosis of the lower intestinal segments. 
In general, meteorism is very moderate and limited to the epigas- 
trium. In marked stenosis the fluid chyme can pass downward 
through the intestinal canal, or find its way upward to the stom- 
ach ; therefore in stenoses of the upper part of the intestines, intes- 
tinal peristalsis, or intestinal rigidity is rarely seen. For the same 
reason severe paroxysms of pain are also absent. 

The clinical picture of deeply situated intestinal stenosis, par- 
ticularly that of the large intestine, is quite different. Here the 
evidences of muscular insufficiency become very prominent. In 
the first place there is constipation, which may be the only symp- 
tom in the beginning, or throughout the disease. Bat constipation 
in itself allows us to draw no conclusion respecting the ominous 
changes occurring within the intestinal lumen. Even this symp- 
tom is sometimes absent. ISTothnagel 2 cites a case of cancer of the 
sigmoid flexure in which natural firm evacuations occurred one day 
before complete intestinal occlusion set in ; and every experienced 
physician can cite similar instances. Although constipation is one 
of the most frequent symptoms of stenosis of the large intestine, 
we may, as in intestinal cancer (page 311), occasionally have the 
reverse condition, namely, diarrhoea. The latter is caused either by 
decomposition of the dejecta above the stricture, or by irritation of 
intestinal ulcers (stercoraceous ulcers, distention ulcers (Kocher)). 
Finally, constipation may alternate with diarrhoea. 

In connection with obstinate constipation, spasmodic pains may 
sooner or later develop. These pains are distinguished from those 
of ordinary flatulent colic by their frequent recurrence and in- 



INTESTINAL STENOSIS 333 

creased duration and intensity. At a late stage they may be con- 
tinuous. 

In contrast to flatulent colic, in which the whole or greater part 
of the abdomen is tympanitically distended, the meteorism even in 
advanced stenosis of the large intestine is generally inconsiderable. 
Only after complete obstruction with intestinal paralysis, do general 
meteorism and simultaneous cessation of intestinal contractions occur. 
When we consider that the gases developed by the accumulated in- 
testinal contents are powerful stimuli to peristalsis, it is not difficult 
to understand why meteorism is absent as long as the functional 
activity of the bowel is preserved. 

The most important accompanying symptom of painful intes- 
tinal contraction is the occurrence of visible, spasmodic intestinal 
peristalsis, a phenomenon which Nothnagel 2 appropriately called 
"intestinal rigidity." These severe visible and palpable spasmodic 
contractions of the intestines in their effort to force their con- 
tents through the stricture, are analogous to the attempt of the 
uterus to force the child's head through the relatively small out- 
let by increased muscular action. This intestinal contraction is a 
favourable symptom in so far as it proves that the hypertrophied 
intestinal muscle still possesses a certain amount of power ; on the 
other hand, it demonstrates that the stenosis is so great that extraor- 
dinary efforts are necessary in order to pass the obstruction. 

In the General Division (page 69) we have already discussed the 
phenomena of intestinal rigidity. We shall return to its significance 
and varieties in the section on diagnosis. 

Formerly great value was laid upon the consistency of the stools. 
It was believed that pointed, narrow- calibred stools were char- 
acteristic of stenosis of the large intestine. This error has found 
its way even among the laity, and every physician can cite cases of 
imaginary stenosis in which the patients complain of constipation 
and habitually examine their own stools. Laparotomy has been 
performed in a number of these patients. 

We now know that in intestinal stenosis the stools have no 
characteristic appearance, for we find similar stools in spasmodic 
constipation, intestinal atrophy, in membranous enteritis, and even 
in ordinary intestinal catarrh. It appears to me that the idea of 
so-called stenotic dejections has originated in great part from stric- 
tures of the lower large intestine (from the sigmoid downward), for 
in that part of the tract characteristic stools do actually occur. 
Under certain conditions, blood, pus, and mucus may be mingled 



384 DISEASES OF THE INTESTINES 

with the evacuations. These anomalies, however, are not peculiar 
to the clinical picture of intestinal stenosis as such, but depend 
upon the underlying intestinal disease. 

Special Symptoms and Diagnosis of Intestinal Stenosis 

In well-marked cases the diagnosis of intestinal stenosis is easy ; 
in other cases only a probable diagnosis can be made ; in some 
the diagnosis is impossible. This depends partly upon the site of 
the occlusion and partly upon the prominence of the symptoms, 
which vary in the different kinds of stenosis. 

(a) Stenosis of the Small Intestine 

Analogous to the classification of malignant disease of the small 
intestine, benign stenoses are also divided into the suprapapillary 
and infrapapillary, jejunal, and ileal forms. As already stated in 
the chapter on Intestinal Cancer (page 335), the diagnosis of supra- 
papillary stenosis is rarely possible. Its clinical picture is so similar 
to that of pyloric stricture, that, despite the most careful examina- 
tion, a correct diagnosis is the exception and a false diagnosis the 
rule. The diagnosis can be made with a fair degree of probability 
only when the subjective symptoms point to the duodenum as the 
certain site of the lesion. In the following case the diagnosis was 
made with the greatest possible clinical certainty before operation. 

Stenosis of the superior portion of the duodenum following an incarcerated 
gallstone. Tetany. Gastro- enter ostomy. Death. 

Mrs. N., fifty years old, has been suffering from attacks of gastric colic for 
over twenty years. These would often cease for years, and later return accom- 
panied by very intense pain. The attacks lasted minutes to hours, and were 
frequently accompanied by chills, fever, cold sweats, and vomiting. Twenty 
years ago had jaundice and clay-coloured stools. She cannot remember wheth- 
er this occurred in an attack of colic or not. 

Patient has been free from attacks for the last eight years, and felt well till 
Christmas, 1897. She then began to have a feeling of discomfort in the epigas- 
trium, and foul-smelling eructations, generally toward evening ; of late there 
have been acid burning eructations early in the morning, and regurgitation of 
stomach contents. Since the end of January there has also been vomiting of 
large quantities of fluid, foul-smelling masses, but not of blood. Patient often 
has the feeling as if the stomach " works strongly " after meals. Always re- 
lieved after vomiting. Marked loss of weight ; appetite good ; constipation 
obstinate. 

Status Prmens. — No evidence of cachexia; skin of yellowish colour. Slight 
emphysema ; heart sounds normal. 



INTESTINAL STENOSIS 335 

Abdomen. — Abdominal walls are moderately fatty; no visible gastric or in- 
testinal peristalsis. When the stomach is empty loud splashing and succussion 
sounds are present to almost a handbreadth below the umbilicus. Epigas- 
trium not sensitive to pressure; no pathological dulness or resistance. The 
border of the liver indistinctly palpable ; hepatic dulness diminished, and 
begins at mammary line at upper border of the fourth rib. Spleen and kid- 
neys negative. 

The vomitus consists of undigested food remnants, is neutral in reaction, 
contains large quantities of sarcinse, yeast fungi, muscle shreds, fat, starch, 
stearic acid bundles. No long bacilli. 

During the next few days the stomach contents were expressed during the 
fasting condition. Each time food remnants rich in HC1, and showing micro- 
scopically the above-mentioned substances, were obtained. The stools consisted 
of scybala, containing enormous numbers of fatty acid crystals. The quantity 
of urine was between 400 and 900 centimetres in twenty-four hours, and con- 
tained an abundance of indican. Otherwise it was normal. 

Treatment. — Fluid and semisolid diet. Daily gastric lavage ; nutrient 
enemata. 

Course. — On March 17th, after complaining of nausea and a feeling of 
abdominal distention, the patient suddenly had a spasmodic attack limited ex- 
clusively to both hands. The fingers were flexed, but could be passively 
extended. Patient was collapsed ; pulse could not be felt ; face cyanotic ; eyes 
staring and glassy; complete consciousness retained throughout the attack, 
which lasted for half an hour. 

Two hours later, despite repeated examinations, neither Trousseau's nor 
Chvostek's phenomena could be elicited. There was no muscular irritability, 
no sensory disturbances. Repeated examinations always gave the same results. 

On March 20th, after previous nausea and abdominal pressure, there was 
numbness and stiffness of the fingers. 

Since the stomach contents always increased, and renewed attacks of tetany 
were feared, the patient was transferred to the private clinic of Professor Hahn 
on March 28th. 

The probable diagnosis was duodenal stenosis, situated high up, consequent 
upon incarcerated gallstones. 

Operation on March 31, 1897, by Professor Hahn. Slight attack of tetany 
during narcosis. 

Laparotomy. — The pylorus is free ; underneath it is felt a large gallstone. 
In order to reach the latter a horizontal incision is made in the region of the 
gall bladder, Gall bladder and parts about the gallstone tightly adherent to 
the duodenum. The gallstone partly compresses the duodenum and partly 
protrudes into its lumen. The adhesions are separated and the stone lifted out 
of its bed, during which manipulation the duodenum is torn. Intestinal 
suture, then gastro-enterostomy. The stone is composed of cholesterin. Col- 
lapse and death the following day. 

In a second case — a bookkeeper, fifty years old — the proba- 
ble diagnosis of high duodenal stricture and calculus, resulting 
from cholelithiasis with icterus which had lasted many years, 



386 DISEASES OF THE INTESTINES 

was made. Gastroenterostomy was performed by Dr. Hahn and 
the diagnosis was confirmed. The patient was cured. 

These two cases are interesting because they show that the sus- 
picion of calculous obstruction of the pylorus and duodenum may 
be awakened by the occurrence of attacks of cholelithiasis for many 
years, and by the later occurrence of dilatation of the stomach. In 
view of the close relation between the gall bladder and duodenum, 
we are justified in suspecting the duodenum as the site of the ste- 
nosis. 

On the other hand, as demonstrated by a case recently described 
by Wegele 3 , the diagnosis of a high calculous duodenal stenosis 
may be very difficult during life, and even during the course of 
operation. 

The diagnosis of low (infrapapillary) duodenal stenosis may be 
made with a much greater degree of probability. This has been 
shown by the more recent observations of Leichtenstern 4 , Calm 5 , 
Eiegel 6 , Hochhaus 7 , Schiile 8 , Eeiche 9 , Herz 10 , Pic 11 , Eewidzoff 12 , 
and myself 13 . From the writings of the authors just mentioned, 
the following may be considered typical symptoms of infrapapillary 
stenosis : 

The most important subjective symptoms are functional dis- 
turbances of the stomach, like those which occur in gastrectasis — 
viz., diminished appetite, feeling of pressure and fulness, or even of 
intense pain after taking food, eructations, nausea, vomiting, con- 
stipation, decreased diuresis, and marked loss of weight and strength. 
If in conjunction with these symptoms there is evidence of previous 
disease of the duodenum and its surroundings (enterorrhagia, duo- 
denal ulcer, disease of the pancreas, gallstones, cholecystitis, cho- 
langitis, and icterus), we must suspect disease of this segment of 
the small intestine. If, furthermore, the vomitus is constantly bile 
tinged, the suspicion becomes a probability, and, as regards the site 
of the stricture, a certainty. 

The objective symptoms chiefly depend upon the disturbed 
stomach motility, the changes in the gastric secretion being of sec- 
ondary importance. The stomach may be of normal size or dilated 
(cases of Eiegel, Schiile, Herz, and others). 

Slight visible peristalsis in the neighbourhood of the pylorus 
may be present, but is generally absent (Schiile). Meteorism is 
only moderate or may likewise be entirely absent. When present, 
it rapidly disappears through the eructations and the vomiting 
(Leichtenstern 4 , Herz). 



INTESTINAL STENOSIS 387 

The constant presence of bile in the stomach is the most impor- 
tant evidence of infra papillary stenosis. This is best observed in 
the morning after the stomach had been washed out the previous 
evening. With the bile the duodenal secretion (succus entericus 
and pancreatic juice) is forced into the stomach, and thus it is some- 
times possible to exclude severe disease of the pancreas by the pres- 
ence of active pancreatic juice (Boas). That under diseased con- 
ditions pancreatic digestion may still continue, is proved by a case 
recently reported by Wilms 14 , of a deeply situated duodenal stenosis 
resulting from compression of a pancreatic cancer. Pertinent con- 
clusions can only be drawn when the digestive tests are negative. 

In these cases the secretion of gastric juice depends upon the 
amount of regurgitated duodenal contents, the duration, and per- 
haps also upon the nature of the disease. Varying amounts of 
HC1 have been found in the different kinds of stenosis of the 
descending portion of the duodenum. According to BiegePs and 
my own experience, the same individual may at one time have 
abundant hydrochloric acid in his stomach, and at other times none 
at all. As I have demonstrated 15 , the presence of bile and of pan- 
creatic juice interferes with the digestive properties of the gastric 
juice only to the extent that the latter is neutralized. If the hydro- 
chloric acid preponderates in the mixture, the gastric juice has as 
active digestive powers as in the normal. On the other hand, in 
such a mixture, even though it be made alkaline, the pancreatic fer- 
ments will be destroyed (probably due to the acid). 

Microscopic examination may show evidences of gastric fermen- 
tation (yeast, sarcinae, bacteria of various kinds, etc.) ; it may also 
show the long bacilli generally found in lactic acid fermentation. 

Discolouration of the stools and increase of indican in the urine 
(Boas) are of diagnostic significance. Both of these changes may, 
however, be absent. According to Herz, bismuth administered by 
the mouth does not reappear in the stool. This can only be the 
case in very marked stenosis of the lower portion of the large intes- 
tine. In connection with other symptoms, it might possess diag- 
nostic value. 

If palpable changes are not present (tumour of the duodenum 
or of its surrounding tissue, adhesions, etc.), the diagnosis of the 
underlying cause of the stenosis is very difficult. The age and sex 
of the patient, and, as already mentioned, the clinical history, are of 
value. In women in whom there is a history of frequent attacks 
of stomach ache, or of icterus, we must suspect impacted stones, 



388 DISEASES OF THE INTESTINES 

which have either ulcerated through the bile duct and produced 
peritoneal adhesions with the duodenum and compression of the 
latter, or small concretions which have passed through the common 
duct into the lower portion of the duodenum, and produced a spas- 
tic obstruction of the latter (cases of Hochhaus, Schule, Herz, and 
others). 

In men in the prime of life we must think of duodenal ulcera- 
tions as the cause of stenosis, especially if the characteristic symp- 
toms of this disease have been present. Several years ago I observed 
and reported two cases of ulcer of the duodenum with resulting ste- 
nosis of the descending portion. In one case, which I shall now 
describe, the autopsy confirmed the diagnosis. 

Deeply situated duodenal stenosis following cicatricial contraction from duo- 
denal ulcer. Gastroenterostomy. Death. 

Patient, a shoemaker, says that since early childhood he has suffered 
from intestinal disturbances (diarrhoea, anorexia, occasional biliary vomiting), 
so that his development was much retarded. In his seventeenth year he 
had typhoid, from which he very slowly recovered. He felt better for a 
time, but frequently thereafter suffered from obstinate vomiting, with diarrhoea. 
Certain articles of food were said to be passed undigested. The patient also 
complained of flatulence, headaches, inability to work, and lassitude. 

Examination showed a poorly nourished man with normal organs of respira- 
tion and circulation. Nothing special found in the nervous system. The 
abdomen is somewhat tympanitic, but no new growth can be made out ; liver 
and spleen normal ; kidneys cannot be felt. In the right hypochondrium, cor- 
responding to a prolongation of the parasternal line, there is a resistance, which 
is sensitive, particularly upon deep pressure. The limits of the stomach are nor- 
mal. After large meals slight splashing can be made out in the epigastrium. 
Distention of the stomach with air plainly shows the larger curvature at the 
level of the umbilicus. The largest diameter obtained by extreme distention 
is 13 centimetres. Rectal examination and insufflation yield nothing special. 

The examination of the stomach contents, made more than 100 times in 
three years, shows the permanent presence of bile and the absence of food 
remnants during fasting. The reaction of the stomach contents was at first 
alkaline ; after a test breakfast they were occasionally slightly acid. The gas- 
tric contents, both in the fasting condition and after eating, always possessed 
peptic power — i. e., pancreatic juice was mixed with the bile. Later the pic- 
ture changed; the gastric contents became acid and gave a decided hydro- 
chloric acid reaction, though the contents were still bile-tinged. After some 
time the first-mentioned condition was again present. There was again dis- 
tinct HC1 reaction. 

The patient's condition varied. Diarrhoea was present. At times the pa- 
tient complained constantly, however, of a painful pressure along the right 
parasternal line, lack of appetite, headaches, fatigue, etc. 

Since these symptoms recurred during the following months, the patient 



INTESTINAL STENOSIS 



389 



consented to a gastroenterostomy ; this was performed in January, 1892. At 
the laparotomy the pylorus was found extremely dilated, so that it was very 
difficult to determine which was the duodenum and which the pylorus. Exter- 
nally, besides a few adhesions of the duodenum to the liver, nothing noteworthy 
was discovered. The patient died the following day. 

Autopsy showed the condition of the stomach and duodenum 
pictured below (see Fig. 31). The pyloric ring was extraordinarily 
dilated, and toward the upper portion of the duodenum almost 
obliterated. The first portion of the duodenum was also extremely 



Pyloric portion 
of stomach 



M 



r. 



Bound ulcers c /"-. .V^--> — ""• <0 


A # 


f c ))) ^ 




"Etat mamelonne" ' S. / 
of duodenum -^ '■/ 

1: 


'Si 


-y\ 


% 


Papilla of Voter- 








Small ulcers """" 




V: 


f 



.Pyloric valve 



J d First portion of 
mJ '* duodenum {consid- 
]U»' erably dilated) 






- - - - . _ /^Cicatricial strand 
^~-* r ~ from ulceration 

I y^ Second portion of duodenum 



Fig. 31. — Ulceb of the Duodenum, with Secondary Stenosis of the Second Portion 
and Dilatation of the First Portion. (Personal observation.) 

dilated and showed several ragged, eroded ulcers. The descend- 
ing portion also contained several similar small ulcerations, some- 
what larger than lentils, with numerous cicatricial strands. The 
latter had considerably narrowed the lumen of the descending por- 
tion. 

Where tubercular symptoms are present we must consider the 
possibility of tubercular ulcerations, though, as shown by a case of 
Herz, 10 under these circumstances other factors may produce the 
stenosis (e. g., in the case just mentioned, a peritoneal strand). 

In advanced age we must first think of cancer of the duodenum 
26 



390 DISEASES OF THE INTESTINES 

and its surrounding parts as the cause of the stenosis. This ques- 
tion is discussed in the chapter on Intestinal Neoplasms, to which, 
in order to avoid repetition, we refer. 

The above list by no means includes all the engendering causes 
of duodenal stenosis. To describe them all would be of no value, 
because the diagnosis is scarcely ever possible during life. It is 
sufficient to simply mention the other possibilities, so that they may 
be taken into account in appropriate cases. These are lymphomata, 
sarcomata, kinking, compression by metastatic tumours, pancreatic 
cysts, fat necrosis of the pancreas, cancer of the pancreas, retroperi- 
toneal tumours, etc. 

Stenosis of the Jejunum and Ileum 

Isolated stenoses of the jejunum and ileum are rare. The ma- 
jority owe their origin to the adhesions and kinking produced by 
inflammatory adhesions with the (female) genitals, the appendix, 
inflamed and reduced hernia, etc. 

In rare instances healed or partially healed tubercular ulcera- 
tions are the cause of the stenosis. Fibrous stenosis, analogous 
to hypertrophic pylorus stenosis, is of anatomical interest only. 
It has been studied particularly by French and English writers 
(" enterite selereuse" "plastic linitis," "cirrhosis intestinalis"), 
and affects partly the stomach and partly the liver, peritoneum, 
and isolated portions of the intestine. Cases of stricture of the 
small intestine from unknown cause (syphilis enteritis) have been 
reported ; only a very few are of carcinomatous nature (Petrina,, 
Chouquet, Letulbe, Broscn, E. Hahn, Reinke, Wernich, Kutt- 
ner 16 ). Tubercular stenoses may occur isolated, but (more fre- 
quently) are multiple. In a case described by E. Frankel 17 , and 
another by Hofmeister 18 , 12 strictures were found. The strictures 
are usually situated in the ileum, occasionally in the caecum, and 
but rarely above or below these parts. 

On the whole, the clinical picture of jejunal and ileal stenosis 
is but little characteristic. The higher the stricture in the jejunum 
the more will the symptoms of disturbed gastric digestion (par- 
ticularly vomiting) preponderate ; and the greater the degree of 
the stenosis the more apt is the vomiting to be fsecal or fecu- 
lent in character. The nearer the stricture is to the caecum the 
more marked are the actual intestinal symptoms — constipation, 
or alternating constipation and diarrhoea, meteorism, severe colic, 
visible and palpable intestinal contraction, particularly in the 



INTESTINAL STENOSIS 391 

middle of the abdomen — symptoms which differ little from those 
of stenosis of the large intestine. 

As shown by the observations of Litten 19 and E. Frankel 17 , 
marked tubercular stenoses of the ileum may run their course en- 
tirely, or almost entirely, without symptoms. If increasing debility 
does not cause death, the condition becomes recognisable by the 
development either of intestinal obstruction or of an acute perfora- 
tive peritonitis. 

In a case of multiple strictures of the small intestine, of unknown character, 
reported by Faber 20 , besides uncharacteristic intestinal disturbances, there 
were marked symptoms of a severe pernicious anaemia from which the patient 
died. Faber explained the pernicious anaemia by absorption of certain toxic 
products which developed above the stenosis. The correctness of the ex- 
planation may be questioned. At all events, the occurrence of progressive 
anaemia in connection with stricture of the small intestine is interesting. 
According to Faber the same observation had already been made by John- 
son and Wallis 21 . 

Since stenosis of the lower small intestine produces symptoms 
only when very far advanced, the diagnosis is very difficult. If the 
diagnosis of a jejuno-ileal stenosis has already been established by a 
careful analysis of the history and of other data, it will not be dif- 
ficult to determine its character. Moreover, as above seen, we must 
always think of the possibility of multiple intestinal stenoses, the 
clinical diagnosis of which, as far as I know, has never been made. 

Differential Diagnosis 

The differential diagnosis must first establish the fact of a steno- 
sis of the upper part of the intestines, and then more exactly define 
the situation as well as the cause of the same. 

The clinical picture of high duodenal stenosis is so similar to 
that of pyloric stenosis, that, as previously mentioned (page 316), 
only especially favourable circumstances can make differentiation 
possible. On the other hand, so far as known, the permanent 
presence of bile in the stomach always points to the existence of 
infrapapillary duodenal stenosis. It is questionable whether the 
absence of bile from the stomach excludes the latter disease. In 
his oft-quoted work Herz concludes that in dilatation of the stom- 
ach the presence of bile may not be recognised, so that the symp- 
toms of pyloric stenosis predominate in the clinical picture. But 
it requires further confirmatory evidence to determine whether this 
difficulty can be overcome by washing out the stomach in the even- 



392 DISEASES OF THE INTESTINES 

ings and examining the contents of the fasting stomach, a pro- 
cedure which I always recommend. 

The above data apply to the differentiation between stenoses 
of the npper segments of the small intestine and those of the 
lower. There is generally great difficulty in distinguishing be- 
tween a deep stricture of the small intestine and stricture of 
the large intestine. Subjectively the occurrence of frequent diar- 
rhoea and the gastric disturbances (nausea, vomiting, anorexia, etc.) 
may be of diagnostic value, but constipation, and alternate con- 
stipation and diarrhoea, may also occur in stenosis of the large 
intestine. Objectively, marked, visible peristalsis may lead to a 
probable diagnosis of the obstruction. We will discuss this more 
fully in the section on stenosis of the large intestine. The lower 
the stenosis the more feculent will be the masses which are 
regurgitated into the stomach. Finally, in deep stenosis of the 
small intestine, particularly when far advanced, more or less me- 
teorism develops. 

In the determination of the cause of the stenosis we must first 
decide whether the process is malignant or benign. If malignancy 
can be excluded, we should look for an etiological connection be- 
tween some previous disease and the benign stricture. In stenosis 
of the upper portion of the duodenum we ought examine for dis- 
ease of the neighbouring organs — of the liver, gall bladder, pan- 
creas, and right kidney. Lower down we must think of adhesions, 
of kinking, of compression — conditions produced by disease of the 
female pelvic organs, the appendix, and by other local peritonitic 
processes. The other varieties of stenosis mentioned above are of 
secondary importance ; although the clinical symptoms be very com- 
plete their diagnosis is sometimes impossible. 

(b) Stenosis of the Large Intestine 

The subjective symptoms are constipation and colic associated 
with nausea and vomiting. The constipation has significance only 
in connection with other symptoms ; it may deserve consideration 
because of the manner of its occurrence. If a patient, particularly 
one in advanced life, in whom the intestinal functions have always 
been normal and who has not changed his diet or way of living, 
suddenly develop constipation, it is always a significant symptom, for 
habitual constipation is not a disease of advanced age, but of youth 
and middle age. Furthermore, its course is to be observed. In 
contrast to simple intestinal atony, this constipation does not develop 



INTESTINAL STENOSIS 393 

gradually, but very rapidly, and it reaches its highest point very 
quickly. Laxatives become useless in a few weeks or months, and 
the patient is soon forced to use drastic cathartics. I have already 
called attention to the great practical importance of circumspection 
in the use of laxatives in constipation. A one-sided view of this 
subject should not, however, be taken, for exceptions are some- 
times met with. 

In other cases the constipation exists for years as a harmless 
complaint, before it becomes more severe. The patient who for- 
merly got along with rhubarb must now use aloes, bitter waters, or 
colocynth, and these always in large doses. 

In addition, spasmodic, paroxysmal intestinal pains call atten- 
tion to the presence of an intestinal obstruction. In conjunction 
with spasmodic intestinal rigidity (soon to be more minutely de- 
scribed), these pains assume a significant character. 

Vomiting is an important and, to my mind, not sufficiently 
valued symptom in stenosis. It recurs with the intestinal colic, and 
in itself presents nothing characteristic. It derives its importance, 
however, from the fact that it is extremely rare in stercoraceous 
flatulency. If the vomiting recurs with each severe attack of 
colic, it ought to warn the practitioner and cause him to suspect 
intestinal stenosis. 

Objective Symptoms. — The most important objective symptoms 
are meteorism, palpable and visible intestinal contractions occur- 
ring at intervals, and changes in the character of the stools. 

The meteorism varies according to the degree and seat of the 
intestinal stricture. It is scarcely appreciable in strictures of the 
rectum (to be described later), considerable in stricture of the 
descending colon, and most extensive when the stricture is in 
the upper segments of the large intestine. It also varies with 
the amount of fulness of the suprastenotic intestinal segments. 
It may be very moderate after abundant evacuation, and in- 
crease considerably after a few days of obstinate constipation. 
It depends upon the sufficiency of the hypertrophic intestinal 
muscle above the stricture — so much so that we should always 
regard increasing meteorism as a precursor of approaching intes- 
tinal paralysis (eventually in connection with peritonitis). As long 
as the lumen is to some extent permeable, the tympanites will 
be inconsiderable, and limited to one or both iliac regions (" flank 
meteorism," Nothnagel **), the mesogastrium, the umbilical region, 

* Loc. cit., p. 375. 



394 DISEASES OF THE INTESTINES 

or the hypogastrium. Therefore, with certain reservations we can 
draw important conclusions regarding the site of the obstruction 
from careful observation of the tympanites. 

We can sometimes define the extent of the tympanitic area by 
percussion, or better, by auscultatory percussion. Nothnagel has 
pointed out that in stenosis of the large intestine, instead of the 
normal more or less marked dulness and low resonance in the 
upper lumbar region posteriorly, there is often a loud and deep 
percussion note ; this is present on both sides in stenosis of the 
sigmoid flexure or of the descending colon, and only on the 
right side in stenosis of the splenic flexure or of the transverse 
colon. 

Visible peristalsis associated with intestinal rigidity is much 
more significant than tympanites. As has been already mentioned 
(page 68), visible peristalsis as such not infrequently occurs nor- 
mally in emaciated individuals, particularly in women with dias- 
tasis of the recti muscles or ptosis of the abdominal viscera. 
It has also been observed as a motor neurosis, which was first 
described by Kussmaul under the name of " tormina ventriculi." 
Both forms, however, are entirely distinct from visible intes- 
tinal peristalsis, for in the latter the intestinal spasm and the 
circular palpable and visible intestinal contraction and rigidity 
are absent. 

In every spasmodic peristaltic action several phases may be 
distinguished : a gradual onset, which is accompanied by mod- 
erate pain ; steady increase of the pain up to its point of greatest 
severity while the bowel is contracted and rigid ; finally, rapid 
abatement of the attack, with the occurrence of palpable and 
audible intestinal sounds — i. e., sounds of gas forced through the 
stricture. 

The intestinal contraction may be limited to a small portion of 
the gut, or whole coils may contract, become snakelike and swol- 
len, and again relax. The former variety (limited contraction) is 
observed principally in stenosis of the colon below the caecum, the 
latter in stenosis of the caecum and small intestine. The degree of 
the stenosis will naturally greatly influence the extent of the tetan- 
ically contracting intestines involved, and the frequency of the 
attacks. 

Can any conclusions as to the seat of the obstruction be drawn 
from the configuration of the intestinal rigidity ? 

Based upon the experience of others and myself in this relation, 



INTESTINAL STENOSIS 395 

this question must be answered in the affirmative. Thus it is 
easy to recognise a csecal stenosis from the active peristalsis of the 
small intestine. Stenoses lower down are also easily recognised if 
rigidity of the large intestine is well defined. Nothnagel* cor- 
rectly states that errors can only arise when the intestine adjoining 
the stricture has lost its power of contraction, and the segment 
immediately above acts vicariously for the latter. 

The important facts regarding the character of the stools in 
stenosis of the large intestine have already been described in the 
chapter on Neoplasms (pages 310 and 311), as well as under the gen- 
eral symptomatology of the present chapter (page 345). In both 
places we have mentioned the slight significance of this symptom, 
and we wish to repeat here that the absence of stenotic stools does 
not exclude the diagnosis of stenosis of the large intestine. The ad- 
mixture of pus and blood in the stools is not characteristic of intes- 
tinal stenosis, but only indicates the presence of complications — 
neoplasms, hemorrhoids, partial or chronic intussusception, ster- 
coraceous ulcers, etc. 

Very rarely all these symptoms are combined. In such instances 
we must be content with a probable diagnosis. At all events, when 
well-defined symptoms of stenosis of the large intestine are present 
the diagnosis will not long remain in doubt. 

The question of the cause of the stenosis is a much more difficult 
one. The history gives us considerable assistance. It may inform 
us respecting previous dysentery, tubercular disease of the intes- 
tine, or of other organs, occasionally of syphilis, appendicitis, peri- 
tonitis, in women, puerperal fever and other diseases of the geni- 
tal tract, incarcerated hernia, intestinal obstruction, abdominal 
operations. In this manner we may gain valuable hints for the 
diagnosis. 

The examination per rectum, and in women per vaginam, is of 
importance and should never be neglected. Thus in an otherwise 
well-defined case of stricture of the large bowel, I was recently 
able to distinctly palpate a contracting coil of small intestine in 
the small pelvis. In some cases vaginal examination, or com- 
bined rectal and vaginal examination, may give important informa- 
tion regarding the situation and character of a suspected stenosis 
of the large intestine. 

The external examination of the abdomen is, however, most 

* Loc. cit., p. 376. 



396 DISEASES OF THE INTESTINES 

instructive. If a tumour can be felt, and its precise nature is in 
doubt, a careful examination is necessary, with especial considera- 
tion of the age of the patient aud the comparative frequency of 
the various tumours (the rarity of benign, the much greater fre- 
quency of malignant neoplasms). 

Differential Diagnosis 

A description of the etiology has already been given. When 
spasmodic intestinal contractions are absent it will be difficult to 
avoid diagnostic errors. This will be the case, for instance, in 
intestinal stenosis when the obstruction is not as yet marked or 
can be easily overcome by contraction of the intestine above the 
stricture. If there is no marked disturbance of nutrition, as 
in intestinal cancer, the patients do not as a rule present them- 
selves for medical examination at this early stage of the disease. As 
already mentioned, the presence of the initial symptoms of stricture, 
be they ever so slight, should make us suspect a mechanical obstruc- 
tion in the bowel. If, in addition, the history confirms our suspi- 
cion and other objective signs of disturbed intestinal functions are 
present (diarrhoeas, blood, pus, and loss of weight), it may be 
possible to make an early diagnosis. It need hardly be men- 
tioned that if tumours, adhesions, and infiltrations about the large 
intestine are found, they offer important data for clearing up 
the diagnosis. Despite these favourable conditions and because of 
the many other etiological possibilities there will always be doubtful 
cases. It is impossible to consider all the differential diagnostic data, 
for we should become lost in the immense literature of the subject. 

B. INTESTINAL OBSTRUCTION (Ileus) 

Intestinal obstruction is a condition in which the lumen of one 
or more portions of the intestines is occluded, and the normal 
forward movement of the contents entirely suspended. Since the 
earliest days of medicine the resulting clinical picture has been 
called ileus (from etXee© = misereor, or elXeay = torqueo). 

In his book on intestinal diseases, Nothnagel advocates the discontinu- 
ance of the term ileus. It is true that the ileus of the older physicians, with 
its extremely vague meaning, has not the same significance as the ileus of 
to-day. The word as used at present may stand as a short and forcible desig- 
nation for intestinal obstruction. For purely practical reasons we shall retain 
the old classification, as accepted by Leichtenstern, of mechanical, dynamic, 
and mechanico-dynamic ileus. 



INTESTINAL OBSTRUCTION 397 

Through interference with the normal course of the faeces at any 
point, a number of severe symptoms soon develops. These gen- 
erally begin suddenly, soon become very severe, and either cease 
spontaneously, or, if not cured by internal or surgical means, cause 
the death of the patient. 

We shall describe those varieties of intestinal obstruction which 
are especially important to internal medicine. The obstructions 
produced by external hernia will be incidentally touched upon, since 
they are treated of in surgical text-books. 

G-eneeal Symptomatology and Diagnosis of Intestinal 
Obsteuction 

As a typical example, let us take an acute obstruction of the small 
intestines due to strangulation : An individual, previously healthy, 
is suddenly seized with severe colicky pains in the abdomen, vomit- 
ing of the ingesta, partially or not at all digested. There is abso- 
lute anorexia, the abdomen rapidly becomes distended, neither faeces 
nor flatus are passed. Intense nausea is present even when the 
stomach is empty. The urine is diminished, or there is anuria. 
There is severe thirst, particularly after repeated vomiting. The 
patient looks very ill as if suffering from a severe acute disease. 

The vomiting consists at first of food remnants, and when the 
stomach is empty is bile-tinged or grayish-green ; gradually it 
becomes feculent, and finally faecal. 

With the onset of the vomiting pain and meteorism may tem- 
porarily cease, giving new hope to the patient and relatives, or 
to the physician. The symptoms very soon become aggravated ; 
the pain reappears, the abdomen becomes more tympanitic, and 
even by the laity the repeated severe faecal vomiting is recognised 
as a sign of intestinal obstruction. 

There is also a marked change in the patient's general condi- 
tion. The lack of nourishment, the loss of sleep produced by the 
pain and vomiting, and, above all, the shock caused by the strangu- 
lation, produce a condition of deep collapse. In sharp contrast to 
the latter, the patient retains full consciousness, and only just before 
death may delirium appear. This condition of extreme collapse, 
which has not inaptly been compared to the algid stage of cholera, 
is soon followed by dissolution. 

This is a short description of a typical case of acute obstruc- 
tion. The several symptoms, and particularly the objective clinical 
picture, require a closer study. To avoid repetition it is best to 



398 DISEASES OF THE INTESTINES 

analyze both together and to point out their significance. For 
this purpose the general symptoms relating to intestinal ob- 
struction will first be considered, and the special diagnosis of 
the several varieties of obstruction will be reserved for later dis- 
cussion. 

The subjective symptoms are pain, nausea, vomiting, retention 
of gas and faeces. 

1. Pain. — This constitutes the main symptom of intestinal 
obstruction. It is present in all forms, but it may vary in inten- 
sity and other characteristics. 

The pain is most intense and continuous in obstruction of the 
small intestine, independent of its anatomical cause. Its severity 
is such that even strong people are overcome. The pains are 
more continuous in character than in stenosis. As I have already 
mentioned in the general division (page 58), Treves 22 gives great 
diagnostic importance to this sign. This is true, however, only 
with certain limitations. The seat and type of obstruction are 
doubtlessly prominent factors. In the first place, as several cases 
of incomplete intestinal obstruction reported by Treves show, 
the pain may be intermittent in character, and this may be the 
case in well-marked obstruction of the small intestines provided 
copious vomiting affords temporary relief to the occluded bowel 
segment. The continuance or discontinuance of the pain may be 
obscured by the use of narcotics and stomach lavage, but we must 
in genera] agree with the conclusions of Treves 22 . It is important 
to note whether the pain, which was continuous, shows marked 
remissions, for with cautious reservations this would point either 
to a favourable termination or to a transition from a complete to 
an incomplete obstruction. 

The localization of the pain possesses on the whole no great 
significance. In the majority of cases the pain is localized in the 
neighbourhood of the umbilicus, but, as Treves has demonstrated, 
this by no means signifies that the site of the obstruction is to be 
sought for in that region. 

We must distinguish between abdominal sensitiveness to pressure 
and subjective pain. The former is generally absent in the begin- 
ning of the disease ; in the later stages it may be either circum- 
scribed or diffuse. Circumscribed pressure sensitiveness occasion- 
ally occurs in the first days of the obstruction ; it then has a certain 
significance, since it points either to an active inflammation of the 
intestine in question or to a local peritonitis. Diffuse sensitiveness, 



INTESTINAL OBSTRUCTION 

in connection with other symptoms (fever, etc.), points to a 
general peritonitis. Treves speaks of another form of sensi- 
tiveness which is developed late in the disease, and which is 
to be looked upon as the consequence of spasmodic intestinal 
peristalsis. In contrast to diffuse peritonitis, this sensitiveness is 
only moderate. 

In all varieties of obstruction pain may cease toward the end of 
the disease. Nothnagel believes this is due to intestinal paralysis 
or to perforative peritonitis, but it is probably also caused by the 
ensuing collapse and lessened vitality. 

2. Vomiting. — This is one of the most regular symptoms of 
the disease. The initial vomiting is no doubt reflex in character, 
analogous to the vomiting of acute peritonitis, of gallstone and 
kidney-stone colic, or of pregnancy. In the beginning the vomited 
matter almost always consists of the stomach contents or mucus, 
and, if severe, contains bile. 

The transition to stercoraceous vomiting is recognised by the 
bringing up of brown, slightly fetid, or feculent masses. "When the 
obstruction has developed very acutely, the vomiting may be faecal 
from the very beginning. Fsecal vomiting consists of fluid, or 
occasionally of fragmentary brownish-yellow or brown-coloured 
masses. Vomiting of formed scybala, which is reported by well- 
known clinicians (Rosenstein ^ Jaccoud 24 , Briquet 25 ), is certainly 
extremely rare. 

Ever since the time of Galen the cause of stercoraceous vomit- 
ing has been the subject of lively discussion. We shall briefly con- 
sider some of the theories which have been offered. 

The old idea that faecal vomiting depends upon perfect or imperfect action 
of the ileo-caecal valve must be given up, in view of the fact that such vomiting 
occurs in obstruction of the small as well as of the large intestine. It must 
be admitted, however, that in the latter instance there is an insufficiency of 
Bauhin's valve, the valve being capable of offering only a certain relative resist- 
ance to the pressure of the stagnant faecal mass. For a long time the exist- 
ence of antiperistalsis has been disputed. That antiperistalsis may occur, 
has been proved by NothnageFs experiments on rabbits with common salt, 
but Xothnagel has never tested his theory in intestinal stenosis. The ex- 
planation given by Haguenot in 1813, as reported by Leichtenstern 26 , is ample 
for the comprehension of faecal vomiting. It is briefly as follows : Strong pres- 
sure is brought to bear upon the site of obstruction by the accumulating faeces 
and gas, and this pressure is increased by every respiration, by every act of 
vomiting, and by every active intestinal contraction. Since the stagnant intes- 
tinal contents have no other avenue of escape, it is apparent that even the act 
of vomiting, accompanied as it is by contraction of the diaphragm and abdom- 



400 DISEASES OF THE INTESTINES 

inal muscles, will force these masses toward the stomach. In like manner, 
the tympanitic intestines may act as stimuli in forcing the stagnant masses 
toward the stomach. Henle appropriately called this an ''overflow" of fluid 
into the stomach. Haguenot's theory also explains why faecal vomiting occurs 
much easier and more extensively in obstruction of the small than of the large 
intestines. 

Because it is easily recognised, faecal vomiting is one of the most 
important symptoms of organic intestinal obstruction. We shall 
see later, however, that it may also be present in simple spastic and 
paralytic intestinal obstruction (compare page 403). 

3. Constipation. — In complete intestinal obstruction constipa- 
tion is generally- absolute, and continues as long as the disease. 
Neither faeces nor gas are passed. To this rule there are a very few 
noteworthy exceptions. Rectal irrigations may wash out small faecal 
particles from the intestines below the site of the occlusion, but 
these are small, and always consist of faeces that were adherent to 
the intestinal walls (Randlcoth). It is important to note that, in 
these cases, flatus is always absent. Besides such stools, Treves 22 
has reported several cases with autopsies, in which more or less 
abundant evacuations were present during the course of the disease. 
Some of these cases he explained by sudden intestinal peristalsis from 
an intercurrent peritonitis (?). The explanation is much clearer in 
two of the cases. In the one instance there was an incarceration of 
about 20 centimetres of the ileum produced by a strand running 
from the transverse colon to the caecum. An intestinal ulcer had 
perforated, the tension of the distended intestines was thus lessened, 
and the incarcerated coil was thereby enabled partly to escape from 
the constricting bands. 

In partial volvulus of the small intestine or sigmoid flexure 
some faeces may be passed. Abundant evacuations are by no means 
rare in acute intestinal invagination. 

In the article already cited, Litten 19 describes a case of multiple 
tubercular strictures of the small intestine, in which both profuse 
diarrhoea and faecal vomiting were present. He correctly concludes 
that there was very advanced though not complete obstruction of 
the bowel. 

Finally, Naunyn has pointed out the paradoxical occurrence of 
evacuations in obstructions by gallstones. When we come to de- 
scribe the various kinds of intestinal obstruction we shall more fully 
analyze these different features, which are so important for the semei- 
ology of this affection. 



INTESTINAL OBSTRUCTION 401 

Objective Signs. — These are tympanites, visible peristalsis, intes- 
tinal hemorrhage, changes in the urine, and disturbances of general 
health. 

1. Tympanites is always present in intestinal obstruction, but its 
amount varies. In acute obstruction of the small intestines, with 
sudden onset, it is relatively slight. The tympanites is extremely 
marked in obstruction of the large intestine, particularly in its most 
frequent form — volvulus of the sigmoid flexure. In the present 
state of our knowledge we may distinguish two forms of tympanites, 
tympanites due to stagnation of contents and local tympanites. 
The former develops in the large or small intestines when the 
lumen is obstructed by foreign bodies, invagination, impacted fasces, 
etc. Fluids and gas stagnate above the stenosis and distend the 
bowel, and the less the amount of gas absorbed the greater the dis- 
tention (Zuntz and Tacker). 

In the beginning of the disease, when the intestinal wall is still 
fairly intact, meteorism will be only moderate ; it gradually increases 
with destruction and over-distention of the intestinal wall. 

Local tympanites, already reported by Kiittner 27 and Hilton 
Fagge 28 , is very much more important than the above form. Its 
importance as a diagnostic factor, however, is due especially to von 
Wahl and his pupils, von Zoge-Manteuffel and Kader, as well as to 
Obalinski and Schlange. Yon "Wahl a first called attention to the 
apparent paradox, that in intestinal obstruction where the tympa- 
nites is most marked (volvulus, invagination, kinking) the coil in 
which the obstruction exists is the most tympanitic, for it is this 
very coil which, through disturbance of its circulation and putre- 
faction of its contents, is the first to be distended by gas. The 
formation of gas is accompanied by considerable distention of the 
bowel wall, and very rapid complete paralysis. 

This distended, resistant, and immovable por- 
tion of the intestine is recognised by inspection 
from the shape of the abdomen, and by palpation, 
from its clearly increased resistance (von Wahl). 

From extensive experiments on animals, Kader 30 has given us 
conclusive proof of von Wahl's theories, and has explained satis- 
factorily the occurrence of local meteorism. This experimenter 
showed that the chief cause of the meteorism lies in the disturb- 
ance of the circulation of the intestinal wall ; the tympanites is 
explained by the increase in the size of the bowel, which is pro- 
duced by the following three factors : infiltration of the intestinal 



402 DISEASES OF THE INTESTINES 

wall, accumulation of fluids in the canal, and the development of 
gases in the interior of the intestine. The bowel segment in ques- 
tion soon becomes distended and tense, often within a few hours. 
Changes in the intestinal wall (oedema, hemorrhagic infiltration, 
thickening of the intestinal wall and its mesentery) occur through- 
out the obstructed segment and are limited to this part. Finally, 
there is gangrene of the intestine, frequently with perforation into 
the abdominal cavity. These perforations are often so minute that 
they are only demonstrable by distending the bowel under water. 
As to the diagnostic value of this fixed, distended coil of intestine, 
when the clinical symptoms are well marked, its presence is doubt- 
less sufficient, and occasionally even conclusive. Its recognition 
necessitates a series of careful examinations. According to the 
description of von Zoge-Manteuff el 32 , the method of the examina- 
tion of this tympanitic coil is as follows : " After the history has 
been taken and the general condition of the patient noted, the 
abdomen should be carefully inspected. The smallest asymmetry 
must be taken into account. We should observe whether the asym- 
metry remains constant, whether it changes with active peristalsis, 
whether intestinal movements become apparent, or whether — and 
this is very important — there be not abnormal quiet beneath the 
tense, distended abdominal walls. Palpation, which follows inspec- 
tion, must attempt to establish differences of resistance. On pal- 
pation, a strangulated, tympanitic coil of intestine feels quite differ- 
ent from the normal intestine containing fluid faeces. Requiring 
more space, it forces itself against the yielding abdominal wall, and 
is thus directly accessible to examination. If vomiting occurs, the 
resulting relief of tension may enable one to grasp this resistant 
segment. This is especially easily accomplished during chloroform 
narcosis." 

The diagnosis of internal incarceration, strangulation, or volvulus 
is facilitated if such a distended immovable coil of intestine is pres- 
ent. Based upon von Wahl's symptom, the diagnosis of these forms 
of intestinal obstruction has repeatedly been correctly made, and the 
cases thereupon successfully operated. But von Wahl's sign is 
not absolutely trustworthy, when, for instance, as he himself 
states, a larger intestinal mass is strangulated. Schede 33 points out 
that the fixed intestinal coil may be covered by distended intes- 
tines lying above the obstruction. Despite all this, however, we 
shall have to look for von Wahl's sign in every case of intestinal 
obstruction. 



INTESTINAL OBSTRUCTION . 403 

2. Spasmodic Intestinal Peristalsis. — Though a classic symptom 
of chronic intestinal obstruction, spasmodic intestinal peristalsis, 
according to the opinion of all careful observers, is one of the rarer 
symptoms of acute intestinal obstruction. Fenwick 34 denies its 
occurrence; Nothnagel* mentions it, but directs attention to the 
great contrast between the marked intestinal rigidity in stenosis and 
its weak contraction in complete occlusion. Schlange 35 , Obalinski 36 , 
and Naunyn 37 consider the slight peristalsis of the "fixed coil "a 
very important symptom of acute intestinal obstruction. The 
first two authors also consider it of practical significance for it 
indicates vital irritability of the bowel ; but this statement is dis- 
puted by von Zoge-Manteufliel. According to Schlange, peri- 
stalsis of the intestine proximate to the obstruction is best ob- 
served in strangulation of smaller coils and in obstruction by 
obturation. Naunyn, who has described a case in point, states 
that this phenomenon may also occur in volvulus without strangu- 
lation. I myself have never observed intestinal peristalsis in acute 
obstruction in the course of a chronic stenosis, and I consider the 
absence of such peristalsis as an evidence of a complete intestinal 
obstruction. 

3. Intestinal hemorrhages may occur under several conditions. 
They are most frequent in intussusception, but, as Henoch and 
Wilms have shown, are occasionally found after herniotomy, after 
reduction of the hernia (Schnitzler), in strangulation, gallstone 
obstruction, and more frequently in volvulus of the sigmoid flex- 
ure and other portions of the intestines. As Tietze M has recently 
demonstrated, hematemesis may occur in intestinal obstruction 
as a result of severe destructive tissue changes in the proximal 
segment. Intestinal hemorrhage is only of significance in con- 
nection with the symptoms. When present, it speaks rather for 
strangulation of the small intestine than for obturation. We have 
already mentioned, in the chapter on Intestinal Carcinoma (page 308), 
that hematemesis may also occur in stenosis of the large intestine. 

4. Changes in the Urine. — The excretion of urine is dimin- 
ished on account of the very rapid collapse, the vomiting and the 
little nourishment taken. This oliguria is not especially charac- 
teristic, but the indicanuria which is frequently present may, 
according to Jafle, have a certain diagnostic significance in re- 
lation to the site of obstruction. Numerous examinations have 

* Log. cit, p. 211. 



404 



DISEASES OF THE INTESTINES 



confirmed JafiVs claims that marked indicanuria is present in 
the first days of obstruction of the small intestine, and may be 
of diagnostic value. If at such time marked indicanuria is ab- 
sent, it would speak rather for occlusion of the large intestine. 
Later in the disease pronounced indicanuria may also occur in 
obstruction of the large intestine, and hence loses all significance. 
If even then no indican is present it would point still more to an 
obstruction of the large intestine. Indican may be increased in 
other affections than intestinal obstruction, and its value must 
always be cautiously accepted. 

What is true of indicanuria is also true of Rosenbach's reaction. 
I have never heard of a marked Eosenbach reaction that was not 
accompanied by an increase of indican in the urine. 

Besides indicanuria we may find albumin and casts, particularly in incar- 
cerated hernise (Englisch 39 , Frank 40 ), and in severe intestinal stenoses (von 
Engel 41 ) ; hemorrhagic nephritis was observed by Israel in a case of volvulus 
of the sigmoid flexure 42 . 

5. General Condition. — In all varieties of intestinal obstruc- 
tion the general condition of the patient suffers greatly. Naturally 
there are differences in the several forms of obstruction. Age, con- 
stitution, and other factors have their influence here as they do in 
other pathological conditions, all, however, being of secondary 
importance to the shock. To a certain extent the degree of the 
shock indicates the site and perhaps the nature of the obstruction. 
Thus it is a well-known fact that in occlusion of the small intes- 
tine, particularly its most frequent pernicious variety — strangula- 
tions and incarcerated hernise — the clinical symptoms very rapidly 
reach their greatest severity. Obstruction of the large intestine, 
on the other hand, is more gradual in its development, and hence 
the collapse is less severe and is more slowly developed. We can- 
not here go into the details of the theory of collapse, in which 
different factors require consideration (reflex action, loss of water, 
intoxication, peritonitis, cardiac insufficiency, etc.). 

6. Clinical Examination. — Clinical examination may give us 
valuable aid. The well-known rule — very careful examination of 
the external hernial orifices in cases of intestinal obstruction — should 
never be forgotten. We must first of all determine whether an 
incarcerated hernia has been actually or partially reduced en masse. 
Medical literature abounds with cases of obstruction due to incom- 
plete or apparent reduction. Digital examination of the vagina 



INTESTINAL OBSTRUCTION 405 

and rectum is quite important, and sometimes gives useful in- 
formation. 

In the general division we have mentioned the most important 
considerations regarding inspection, percussion, auscultation, and 
palpation. I would again mention the diagnostic value of auscul- 
tatory percussion, first described by Leichtenstern * and later by 
Curschmann ^ by means of which it is often possible to localize dif- 
ferent portions of the intestines. 

The significance of distention of the rectum with air and liquids 
has already been treated of at length in the general division. We 
again repeat that these methods may serve to confirm a diagnosis of 
obstruction in the lower portions of the intestine, though they are 
useless in obstructions higher up. 

Differential Diagnosis of Intestinal Obstruction 

If the clinical picture of obstruction is well developed, and its 
course can be followed from the onset, the differential diagnosis 
between ileus and its related conditions is rarely difficult. If, 
however, the beginning be obscure, the symptoms not well marked, 
or complications present, the diagnosis becomes very difficult. 
Among the conditions which are generally easily differentiated 
from intestinal obstruction are flatulent colic, cholelithiasis and 
nephrolithiasis, poisoning, and cholera. 

1. flatulent Colic. — If observed in the earliest stages, differen- 
tiation between intestinal obstruction and flatulent colic may be 
difficult, particularly if the severe symptoms of obstruction have 
gradually developed. The history, clinical examination, and the 
further course of the disease are important in this connection. 
The history shows that the patient has often suffered from similar 
attacks as well as from irregular bowels. Symptoms of severe 
shock are absent in intestinal colic. Though flatus is generally 
not passed in such cases, some gas may be passed and thereby relief 
obtained. Vomiting, one of the early symptoms of intestinal ob- 
struction, is very rarely present in simple flatulent colic. Further 
observation will scarcely ever leave any doubt as to the nature of 
the disease. 

2. Gallstone and Renal Colic. — In the beginning of the attack 
biliary and renal colic may very much resemble intestinal obstruc- 
tion, especially an obstruction situated high up. Here, again, the his- 

* Loc. cit., p. 407. 

27 



406 DISEASES OF THE INTESTINES 

tory is important. Biliary and renal colics usually occur late in life, 
intestinal obstruction is found at all ages. It may be possible to pal- 
pate the gall bladder or an enlarged painful liver or painful kidney. 
The presence of slight icterus or of urine containing a small amount 
of bilirubin, or of cloudy urine containing a marked sediment, may 
point to the correct diagnosis. Finally, the presence of very marked 
indicanuria in the beginning of the disease may aid in the differen- 
tiation. "With careful observation the diagnosis should soon be made. 

3. Poisoning has several times been mistaken for obstruction. 
On the whole, however, error can only occur when no history can 
be obtained or when the disease runs a very atypical course. 

4. As recent reports have shown, cholera nostras or Asiatica 
may cause dangerous mistakes, especially during a cholera epi- 
demic, and particularly when that rare complication of obstruction 
first described by Malgaigne — obstruction with profuse diarrhoeas 
(cholera herniaire) is present. However, careful bacteriological and 
other examination should nowadays make errors of this kind im- 
possible. 

5. Peritonitis and Perityphlitis. — Here, again, the history is 
the most important, occasionally the only, aid in differential diag- 
nosis. No circumstance in the present or previous history that may 
have some connection with the disease should be neglected. Thus, 
a previous typhoid, hematemesis, dysentery, or appendicitis may 
clear up an otherwise obscure case. If the history renders no aid, 
the differentiation is very difficult in cases which are at all compli- 
cated, particularly where the onset was not sufficiently observed. 
Is there intestinal obstruction only, or obstruction and secondary 
peritonitis, or primary peritonitis, and — what is always pertinent to 
etiology — what is the nature and origin of the process in question ? 

Positive differentia] signs do not exist, since mild peritonitic 
symptoms may be present in the early stages of intestinal obstruc- 
tion and thereby lead to error. By a consideration of all the 
important symptoms of both conditions it will be easier to arrive at 
a correct diagnosis. These include fever, sensitiveness to pressure, 
tympanites, abnormal peristalsis, vomiting, ascites, and changes in 
the urine. 

~No positive conclusions can be drawn from the presence or 
absence of fever. In diffuse peritonitis it may be entirely absent, 
whereas in intestinal obstruction the fever, when present, is apt to 
be only moderate. High fever from the very onset (39° C. and 
over) would, in itself, indicate acute, diffuse peritonitis. 



INTESTINAL OBSTRUCTION 407 

The sensitiveness to pressure is sometimes of diagnostic impor- 
tance, but may be absent in peritonitis and be very marked in 
obstruction. Still, sensitiveness to pressure is generally much more 
accentuated in peritonitis than in obstruction ; in the latter it is 
severe only when peritoneal complications are already present. The 
situation of the area of sensitiveness is also of significance. If from 
the beginning it has been localized in the right iliac fossa and has 
remained there, the assumption of a perforative peritonitis follow- 
ing perityphlitis is much more probable. 

In like manner the tympanites is to be cautiously employed 
as a differential factor. In peritonitis, as in obstruction, it may 
be extensive or entirely absent. When present in peritonitis it 
soon becomes general. This is in sharp contrast to some forms 
of obstruction (strangulation) in which, as we have already seen, 
meteorism is distinctly localized as long as there is no intestinal paral- 
ysis. But even this symptom becomes only a theoretical distinctive 
characteristic when we are dealing with a large sacculated peri- 
toneal exudate which may produce the same physical signs as a 
distended coil of intestine in obstruction. 

Well-marked, visible, and palpable intestinal peristalsis is a valu- 
able symptom of intestinal obstruction, but unfortunately it is absent 
in the greater number of cases. Besides, slight evidences of peri- 
staltic motion may easily be overlooked. The absence of all intes- 
tinal motion and sounds tends to support the diagnosis of peritonitis, 
but even this is no convincing proof. 

Vomiting is a symptom of both diseases, and may make difficult 
or frustrate all differentiation. The early appearance of fgecal vom- 
iting speaks rather for obstruction than for peritonitis. Though 
faBcal vomiting occasionally occurs in peritonitis with intestinal 
paralysis, it is by no means as frequent as in intestinal obstruction. 
The occurrence of a fluid exudate is found in peritonitis as well 
as in several forms of intestinal obstruction (volvulus, strangula- 
tion) ; this sign therefore possesses no differential significance. 

The same is true of the amount of indican in the urine, which 
may also be much increased in acute peritonitis. The absence of 
marked indicanuria may, in connection with other signs, speak for 
obstruction of the large intestine. 

The greater part of what has been said above also applies to peri- 
typhlitis, which is the most frequent cause of perforative peritonitis. 

It is evident that those cases only ought to be differentially con- 
sidered in which the clinical picture of severe intestinal obstruc- 



408 DISEASES OF THE INTESTINES 

tion is present. Aside from the history of the case, which may give 
us valuable information, distinct localized pain over McBurney's 
point, even in a case of indirectly developed diffuse peritonitis, 
moderate resistance, increased rigidity, or oedema of the abdomi- 
nal muscles, may indicate the correct diagnosis. Where, as not 
infrequently happens, these data are absent the diagnosis will long 
be doubtful. 

Symptomatology and Diagnosis of the Various Kinds or 
Intestinal Obstruction 

I. External Intestinal Obstruction by Bands, Clefts, 
Fenestra, and Internal Herniae 

Of all types of obstruction the above variety is scientifically the 
most interesting and the most frequent, but unfortunately diag- 
nostically the most unfruitful. There are innumerable possibilities, 
and it would require a monograph to carefully analyze and discuss 
the different varieties of this type of obstruction. 

We will therefore content ourselves with a brief description 
of its most frequent forms. Since I have had but little experience 
with these various types, I shall follow the excellent description 
of Treves 22 . 

Treves distinguishes five varieties of external intestinal obstruc- 
tion. 

1. Strangulation oy Isolated Peritoneal Adhesions 

Since chronic local peritonitis is an extremely frequent condition, it is 
apparent that it is a prominent factor in the etiology of intestinal obstruc- 
tion. Generally one peritoneal adhesion is present (see Fig. 32), rarely there 
are several. This fact is of great surgical importance, for occasionally during 
operation the obstruction is thought to have been overcome by ligation of a pseu- 
do-ligament, but the continuance of the obstruction and Autopsy show the pres- 
ence of a second adhesion, the real cause of the constriction. The adhesions 
in question are circular or in the form of strands, and vary considerably in 
length and thickness ; they vary from the size of a thread to that of a finger. 
According to Treves, the average length is 4 to 5 centimetres. Naturally, every 
adhesion which strangulates the intestine must have at least two points of 
attachment. One of its ends is very frequently connected with the mesentery. 
In other cases both ends are thus attached, and then the points of insertion are 
far apart (see Fig. 33, page 371). The number of possible attachments is as large 
as the possible adhesions of the intestines with each other and with the remain- 
ing abdominal organs. "There is scarcely any conceivable combination 
of connected areas which is not illustrated in the history of these adhesions " 
(Treves [p. 34]). 




Fig. 82. — Strangulation by a Beoad Peritoneal Band passing between Two Adja- 
cent Coils of the Ileum. (Treves.) 




Fig. S3. — Strangulation of Small Intestine by a Solitary Band attached at Either 
End to the Mesentery. (Treves.) 



410 



DISEASES OF THE INTESTINES 



It is a fundamental observation that some portion of the small intestines 
is most frequently constricted, and that its most movable segment, the ileum, 
is generally affected. 

The organs from which the bands most frequently originate are the female 
pelvic organs (pelvic peritonitis) and the caecum and 
appendix. The number of possible variations still in- 
creases when we consider the frequent anomalous dis- 
placements of the several intestinal segments. 

Besides strangulation by isolated peritoneal adhe- 
sions, there is another form in which, because of peri- 
tonitis, movable organs become fixed and thereby give 
rise to obstruction. To this category belong particu- 
larly the vermiform appendix, Meckel's diverticulum 
(see opposite page), and in rarer cases the Fallopian 
tubes, appendices epiploic*, and the mesentery, which 
is changed into a strand. These organs form either 

a band or an arch under which the intestine becomes 

Fig. 34. — Strangulation . . . ., . „ .,. ,., ■« . 

of a Small Intestinal constricted, or they form a coil in which a portion of 

Coil by a Long Liga- tne bowel is caught. The first is the more frequent 

mentous Strand. occurrence (see Fig. 34). 




2. Strangulation through Clefts and Fenestra 

This type of obstruction is rare and hence possesses only slight practical 
importance. Clefts and fenestra are found most frequently in the omentum 
and mesentery. They may be congenital, but 
are generally produced by trauma or by peri- 
toneal inflammatory products, or they consist 
of spaces which have been formed by peri- 
toneal adhesions between different organs (uter- 
us, ovaries, hernial canals, appendices epi- 
ploic*, etc.). 

Discussion of the several forms and varieties 
is not apjDropriate to the scope of this work ; we 
therefore refer to the thorough descriptions of 
Treves 22 and Leichtenstern \ 

3. Strangulation oy Omental Bands 

As strands are caused by peritonitis, so bands 
may also develop from inflammation of the 
mesentery. The latter (mesenterial bands) are 
much larger in size than the former (see Figs. 
34 and 35). They originate from traumatism, 
pelvic peritonitis, or, in the majority of cases, 
from peritonitis about a hernial sac, especially 
femoral hernia. The left side is more apt to 
be involved because the omentum generally lies 
in that half of the abdomen. As with peritoneal adhesions, so two or more 
mesenteric ligaments may be present. 




Fig. 35. — Internal Strangula- 
tion of an Intestinal Coil 
by a Strand passing from 
the Omentum or Transverse 
Colon to the Anterior Ab- 
dominal Wall. (Konig.) 



INTESTINAL OBSTRUCTION 



411 



4. Strangulation In/ Meckel's Diverticulum 

As is known, Meckel's diverticulum is due to a pervious or an incompletely 
obliterated omphalomesenteric duct. The abdominal end of the diverticu- 
lum is generally free; only rarely is it adherent to the umbilicus as a solid strand 
or pervious canal. It is evident that free mobility of the diverticulum is 
the most frequent cause of knotting and volvulus. 
but it sometimes forms a bridge under which 
intestines become incarcerated. This type of 
strangulation is generally the result of fixation of 
the diverticulum by peritonitis. The diverticu- 
lum is usually adherent to the mesentery, but it 
may also adhere to other portions of the intes- 
tines, the omentum, caecum, small intestines, or to 
the pelvic organs, thereby possibly causing intestinal 
incarceration. 

When the diverticulum is abnormally long and 
has a kind of club-shaped swelling at its free end, 
a not infrequent type of obstruction may occur. 
The diverticulum may form a sort of slipknot in 
which the ampulla, being the thicker portion, tends 
to tighten the knot (hence called by the French 
"clef de I 'etrangleme?it") (see Fig. 36). We pass 
over several other forms of obstruction which 
are described by Treves, as they are more infre- 
quent. 




Fig. 36. — Internal Strangu- 
lation of a Loop of 
Shall Intestine by a 

Meckel's Diveeticuluh 
coiled about it. 
a, attachment of the divertic- 
ulum to the intestine, b. 
its club-shaped end (Keg- 
nault-Beclard). 



5. Strangulation from Internal Hernia 

According to Leichtenstern, internal herniae are those which lie either en- 
tirely within the abdominal or thoracic cavities, or which are situated retro- or 
subperitoneally, parallel to the abdominal wall and protrude into the abdomi- 
nal cavity, but never, even by continued growth, appear externally. 

By external herniae we mean those which push the peritoneum in an exter- 
nal direction, and which, by continued growth, become externally visible 
tumours. Leichtenstern, who has given us the most thorough description of 
this subject, distinguishes three forms : 

1. Very small, external hernise, which, particularly in fat individuals, may 
remain latent throughout. 

2. Interstitial herniae which run their course under the clinical picture of 
an internal hernia. They originate from the different hernial canals, most fre- 
quently from the inguinal. They occur either alone or in connection with 
external inguinal or femoral herniae, whose subsidiary swelling they represent. 
Interstitial herniae are generally the result of taxis and efforts at reduction. 
Interstitial incarceration has often been observed in the presence of mobility of 
the main hernia. 

3. Finally, the following very rare herniae — important only surgically and 
anatomically — run the course of the internal herniae, viz., obturator, sciatic, 
perineal, rectal, vaginal, and lumbar herniae. 



412 DISEASES OF THE INTESTINES 

With the exception of diaphragmatic hernia, true "internal hernias " can 
hardly ever be diagnosticated. We therefore limit ourselves to the mention of 
their names, and again refer to the exemplary description of Leichtenstern. This 
author gives the following varieties of true internal hernia : hernia retro-peri- 
tonealis anterior (hernia iirtra-iliaca, ante-vesicalis, retro-pubica, hernia interna 
vaginalis testiculi, hernia iliaco sub-fascialisj, hernia duodeno-jejunalis (Treitz's 
hernia, of which about 50 cases have been described), hernia pericascalis, hernia 
intersigmoidea, hernia intra-epiploica, hernia ligam. uteri lati, hernia fora- 
men Winslowii, and, finally, hernia diaphragmatica. 

There are two forms of diaphragmatic hernia, the true and the false. The 
former name is applied to those cases in which an abdominal organ or organs 
have entered the pleural cavity through an opening in the diaphragm, and 
which have as hernial covering either pleura or peritoneum, or both. The latter 
name (false) is applied to those cases in which the abdominal viscera pass through 
an opening both of the diaphragm and of the contiguous serous membranes 
(pleura and peritoneum), the abdominal organs coming into direct contact with 
the thoracic. Such visceral displacements must be looked upon rather as a 
prolapse or ectopia than as a true hernia. Most diaphragmatic hernias are 
"false." Of 254 cases, only 28 were true. 

Entrance of the abdominal viscera into the chest cavity is caused either by 
congenital defects of the diaphragm, by a physiologically preformed fenestrum, 
or by an absence of continuity in the diaphragm from inflammation or (more 
often) traumatism. 

Congenital defects occur most frequently in the muscular portion of the 
diaphragm, usually to the left side (in the proportion of 98 to 19), and occa- 
sionally extend over an entire half of the diaphragm. Acquired diaphragmatic 
hernias are also generally leftsided; the pla.ce of entrance is more frequently in 
the posterior than in the anterior portion of the midriff. 

The preformed openings in the diaphragm which may give rise to hernias 
are (1) the esophageal opening ; (2) the foramen of Morgagni (in that portion 
of the midriff corresponding to the sternum and the seventh costal cartilage of 
either side) ; (3) the foramen of Bochdalek (posteriorly between lumbar and 
costal division of the diaphragm) ; (4) the point of entrance for the sympa- 
thetic nerve (between the external and median crura). 

The abdominal viscus most frequently displaced is the stomach; then follow 
the transverse colon, omentum, small intestines, spleen, liver, pancreas, and 
kidney. The greater curvature of the stomach is regularly found uppermost, 
and the lesser curvature below. If the fundus alone be involved, and not the 
pylorus, volvulus with incarceration of the stomach may follow. Two or more 
organs are generally displaced. When only one viscus is displaced it is usually 
the stomach, less frequently the colon, small intestine, or omentum. Most 
cases of diaphragmatic hernia are accidentally discovered at the autopsy. They 
sometimes produce significant symptoms, which under favourable circumstances 
may lead to a diagnosis during life. Leichtenstern 44 , who first successfully recog- 
nised a case of diaphragmatic hernia, considers that the diagnosis may be made 
if pneumothorax can be excluded, and if it can be proved that there are in the 
thoracic cavity other air-containing organs, which upon auscultation and per- 
cussion present differences depending upon their varying conditions of fulness. 



INTESTINAL OBSTRUCTION 413 

Filling up the stomach or colon with air or water may aid the diagnosis. Dis- 
placement of the heart to the right is also of diagnostic significance (P. Gutt- 
mann 45 and Abel 46 ). Finally, trans-illumination of the stomach, particularly, 
its radiograph (by the introduction of a soft metallic sound), ought to make 
diagnosis possible. 

Symptomatology 

Before discussing the individual symptoms of these forms of ob- 
struction we must mention several facts of great practical impor- 
tance. 

First of all as to the seat of incarceration. In the overwhelming 
number of cases the ileum is the segment affected ; the other intes- 
tinal segments, both above and below the ileum, are so rarely affected 
that they hardly come up for consideration. The cause of this fre- 
quency of ileal incarceration lies in its anatomical position, and in 
the possibility of its coining into contact with all those other organs 
which are most apt to be incarcerated (mesentery, great omentum, 
Meckel's diverticulum, vermiform appendix, pelvic organs, hernial 
canals, etc.). 

The age requires consideration. Though incarceration may occur 
at all ages, yet statistics show that it is essentially a disease of early 
life, that it is most frequent in the second decade, and that it occurs 
only exceptionally in the later periods, or in the first decade. 

Sex is also a factor, though the difference in this particular is 
not sufficiently marked to allow of positive data to be based there- 
upon. In women the puerperium and the diseases incidental thereto 
are considered as predisposing factors. We find that appendix 
affections, herniEe, traumatism, and Meckel's diverticulum act more 
frequently as predisposing factors in the male than in the female, so 
that the proportion of incarcerations is, according to Leichtenstern, 
180 males to 118 females. 

In its important details the clinical picture of incarceration coin- 
cides with that already given under general symptomatology. While 
referring to the latter we again point out certain important symp- 
toms which are particularly prominent in the clinical ensemble. Thus 
we would mention the acute onset in the midst of normal health or 
after a slight illness, or occasionally after a traumatism, the violent 
development of symptoms finally leading to death, the severe pain, 
the vomitus rapidly becoming feculent, the complete retention of 
stool and ffases and contrasting strangelv with the absence or onlv 
slight presence of meteorism, the retention of urine, rapidly in- 
creasing debility, collapse amid complete consciousness, and the 



414 DISEASES OF THE INTESTINES 

absence of fever when the case is not complicated by peritonitis. 
The few exceptions to this type are characterized by a less violent 
development of symptoms. The course of the disease may be less 
sudden and show deceptive remissions. These differences mainly 
depend upon the form and degree of the obstruction. 

Diagnosis 

Not only the presence of an incarceration or strangulation, but 
also its location and nature must be determined. Occasionally, 
favourable circumstances — a history which points directly to the 
source of obstruction — allow of a correct diagnosis being made, 
but in the large majority of cases the diagnosis is impossible. If 
we have diagnosticated internal strangulation, we may assume the 
site of the obstruction to be in the lower ileum, since that portion 
is more frequently involved. Regarding the differentiation of this 
(internal) from other forms of obstruction, we shall only mention 
the most important points which enable us to recognise the condi- 
tion in favourable cases : early period of life, a history of inflam- 
matory processes in the abdominal cavity or of the pelvic vis- 
cera, previous traumatism, previous laparotomy, very acute onset of 
severe symptoms, absence of tumour, absence of marked mete- 
orism, the presence of a fixed, inflated coil of intestine and per- 
haps visible peristalsis, hemorrhagic exudate, and the absence of 
bloody stools. (Compare in this connection the differential diag- 
nosis, page 407.) When the case is complicated by peritonitis the 
diagnosis, as a rule, cannot be made. 

II. Volvulus 

Preliminary Observations. — By volvulus we understand a tor- 
sion of the intestine about its mesenteric axis, or the knotting to- 
gether of two coils of gut. We must consider volvulus of the 
sigmoid flexure (the most frequent and practically the most impor- 
tant form), volvulus of the ascending colon, and volvulus of the 
small intestine. 

Yolvulus of the sigmoid flexure is found in two thirds of all the 
cases, and occurs when the sigmoid is very long, and its mesocolon 
long and narrow, so that the ends of the arch are brought nearer to 
each other (see Fig. 37). It is quite apparent that under such con- 
ditions volvulus, with the mesentery as the axis, may easily occur. 

The causes of volvulus are direct and indirect (predisposing). 
Of the latter the following may be mentioned : congenital predis- 



INTESTINAL OBSTRUCTION 



•±15 



position (an abnormally long sigmoid with a long, narrow mesen- 
tery i, habitual constipation, a purely vegetable diet (which, accord- 
ing to Lingen and Kiittner, explains the frequency of volvulus in 
the peasants of Russia), and peritoneal inflammation in the neigh- 
bourhood of the sigmoid flexure, with 
consequent cicatrization of its mes- 
entery (mesenteritis, see page 394). 
Trauma, marked natural or artificial 
intestinal peristalsis or its reverse, 
acute intestinal paresis, errors of 
diet, foreign bodies, gallstones, dys- 
entery with consequent cicatrices, 
tumours, laparotomies, etc., are di- 
rect causes of volvulus. Undoubt- 
edly faecal impaction is the most fre- 
quent cause of volvulus. It occasions 
a sinking of the upper limb of the 
sigmoid flexure upon the lower, or 

the lower limb gradually approaches the upper till finally the volvu- 
lus is completed by severe peristalsis, induced perhaps by a strong- 
drastic purge. In most cases there is a torsion of ISO degrees, inore 
rarely of 360 degrees. The torsion takes place about the mesenteric 
axis, and also, to some extent, about its [intestine] own axis. In these 




Fig. 37. — Sigmoid Flexure shottexg a 
Texdexcy to Volvulus Forha- 
xiok. "Treves.! 





Fig. 38. 
Type Bectem ex Arriere. (Potain.) Type Rectum: ex Avast. (Potain.) 



cases either the descending colon lies in front of the rectum (type 
rectum en arriere, Potain), or the rectum lies in front of the colon 



(type rectum en avant) (see Fig. 



38, A. 



B). The former type is by 



416 DISEASES OF THE INTESTINES 

far the more frequent. If the volvulus be complete (i. e., torsion of 
270 to 360 degrees), spontaneous untwisting is impossible, because 
of the changes which soon occur in the affected limb of the sigmoid 
flexure (accumulation of blood, exudation, formation of gas), and 
in that lying above it (intense meteorism, intestinal paresis). Ac- 
cording to experiments of Melchioris 47 , the resistance of the abdomi- 
nal wall also prevents untwisting. Finally, peritonitis will contrib- 
ute to the fixation of the volvulus. Spontaneous untwisting may 
follow incomplete volvulus. 

As already stated, volvulus of the other segments of the large 
intestine (caecum, transverse colon) is extremely rare. The condi- 
tions under which it occurs are similar to those of volvulus of the sig- 
moid. Somewhat more frequent, though still quite rare, is volvulus 
of single or several coils of small intestine. The amount of torsion 
is generally about 180 degrees. Usually the upper end of the small 
intestine lies below and to the left, and the lower end above and to 
the right. The intestines and mesentery lying to the right are 
transposed to the left, and vice versa. The intestinal obstruc- 
tion need not be complete. Volvulus of this kind occurs even in 
earliest childhood. According to Leichtenstern 1 , congenital mal- 
formation of the mesentery, in which ileum, caecum, and ascending 
colon have a common mesentery, seems particularly to predispose 
to volvulus. Volvulus of the small intestine occurs most fre- 
quently in coils which have for a long time been either in a large 
hernial sac or in its vicinity, or which have become adherent to pel- 
vic viscera (Leichtenstern). 

"We have mentioned that the volvulus usually occurs about the 
mesenteric axis of the bowel. Besides this there is a true torsion 
about the intestinal axis ; such cases generally affect the large intes- 
tines, particularly the caecum and ascending colon. Leichtenstern 
considers most of them as kinking following displacements. These 
volvuli need not produce complete obstruction ; this may only occur 
when other changes are superadded — for example, when the mesen- 
tery of a coil of small gut is thrown across the place of kinking. 

Finally, we must briefly describe the knotting together of two 
intestinal coils. The sigmoid flexure and the ileum are most often 
twisted about each other (see Fig. 39). Much more rarely there is 
knotting or coiling together of small intestine, or a twist of the jejuno- 
ileum, caecum, and ascending colon. In the first-mentioned instance, 
according to Leichtenstern, the most frequent occurrence is the dis- 
placement of small intestine across the narrow mesentery of the 



INTESTINAL OBSTRUCTION 



417 



sigmoid. Through the space which is thus formed bj the posterior 
abdominal wall and the roots of the crossed coil of small intestine 
and sigmoid flexure, the superior 
portion of the sigmoid enters, after 
passing from below upward in front 
of the small intestine. The clinical 
course of this knot formation is 
exceedingly acute ; it is fatal in 
one or two days. Such forma- 
tions are frequently ushered in by 
violent diarrhoeas, which may re- 
main pronounced throughout the 
course of the disease, to which they 
lend a certain similarity to cholera. 

Symptomatology 



what follows we shall de- 
more especially the clinical 




Fig. 39. — Schematic Drawing to il- 
lustrate a Knotting Together or 
Ileum ( I) and Sigmoid Flexure (S). 
B, rectum. (Leiehtenstern.) 



In 

scribe 

symptoms of sigmoid volvulus. Be- 
cause of their rarity and the ob- 
scurity of their symptoms the other 

forms have but little clinical interest, and will be very briefly de- 
scribed at the end of this section. According to most clinicians, 
volvulus is a disease of late life (forty to sixty years). In 20 cases 
Treves 22 found the average age forty-nine years. In his statistics 
Leiehtenstern 1 found only one case in the first decade. Men seem 
to be more predisposed to this affection than women ; Treves gives 
the proportion as 4 to 1. The occurrence of volvulus late in life 
is explained by the fact already mentioned (page 377), that it 
develops most frequently in connection with habitual constipa- 
tion, which is most severe in the fourth to the sixth decades of 
life. In view of the fact that obstinate constipation is so frequent 
in women, it is rather striking that the majority of cases of volvulus 
should occur in men. Perhaps more extensive statistics will show 
that the female sex is after all more prone to this affection. 

Except for occasional acute attacks, the varieties of intestinal 
obstruction already described generally present no evidences of 
previous intestinal disease ; chronic constipation really forms the 
initial stage of an affection which finally ends with an attack of 
volvulus. 

The pernicious character of the constipation is often appar- 



418 DISEASES OF THE INTESTINES 

ent from the history. The constipation increases steadily, and 
increasing doses of drastic purges produce only incomplete evacua- 
tions of a spastic or diarrhoea] character, accompanied by severe pain 

and perhaps by nausea and vomiting. After a longer or shorter 
period volvulus suddenly occurs. 

As in other varieties of intestinal obstruction, the main symp- 
toms are pain, vomiting, complete intestinal occlusion, disturbance of 
general health. Excepting that they are less violent, all these symp- 
toms differ but little from those of obstruction of the small bowel. 

Pain, the first and most striking symptom, is quite marked, but 
is not so severe or continuous as in incarceration or strangulation. 
It is intermittent, and is relieved by small doses of opium. The 
patient may be able to obtain sleep without narcotics, and other- 
wise present a certain euphoria. The pain is usually most pro- 
nounced about the umbilicus, more rarely it is found in the vicinity 
of the sigmoid itself. Tenesmus may accompany the pain, but even 
in well-denned cases of volvulus it may be absent. If peritonitis 
sets in. the pain is increased and becomes more diffuse. 

Sensitiveness to pressure may be absent in the beginning of the 
affection : later, the tenderness becomes easily demonstrable, and 
is generally localized in the umbilical region. ^larked increase 
in the degree and area of this sensitiveness to pressure is always a 
suspicious sign of beginning peritonitis. 

In the beginning, the vomiting is reflex and accompanies the 
paroxysms of pain. Occasionally vomiting is entirely absent, and 
then nausea or severe explosive eructations occur, followed by 
momentary relief. The vomitus is by no means very copious ; at 
first it consists of the stomach contents mixed with mucus, later, 
of grayish green or brownish masses with a slight " intestinal odour." 
As stated by Treves,* the vomiting is very rarely stercoraceous. 
If in the presence of weH-defmed symptoms stercoraceous vomit- 
ing occurs quite early, it always indicates an unfavourable termi- 
nation of the disease. 

As in the other forms of intestinal obstruction, anorexia and 
very severe thirst occur also in volvulus. 

Usually, from the very beginning of the disease neither faeces 
nor flatus are passed. Small quantities of faecal masses come away 
with the enemata or rectal irrigations, but. as already mentioned, 
no flatus accompanies such evacuations. If purges or enemata do 

[* Loc. cit.. p. 299.] 



INTESTINAL OBSTRUCTION 419 

produce stools accompanied by flatus, incomplete volvulus should 
be suspected. A single evacuation of this kind should not make 
the phvsician too sanguine, for experience has shown that an incom- 
plete volvulus may readily become complete through peristalsis. 
Therefore the general condition of the patient is more significant 
than the condition of the stool. Occasionally blood has been found 
in the evacuations. 

Local tympanites is a very important and characteristic symp- 
tom of volvulus of the sigmoid ; in no other form of intestinal 
obstruction is this symptom so prominent from the very beginning 
of the disease. The meteorism is not limited to the neighbourhood 
of the sigmoid flexure ; on the contrary, this latter region is gener- 
ally occupied by coils of small intestine. As previously mentioned 
(page 23), the tympanites extend toward the right in front and 
upward. Curschmann 48 has made the important observation that 
in this disease one may find tympanitic intestinal coils over the 
entire abdomen, but not at the site of the volvulus — i. e., in the 
vicinity of the sigmoid. Here von Wahl's symptom of distended 
intestinal coils may be very well demonstrated (page 363). If 
peritonitis develops, the meteorism gradually becomes general, and 
it is then impossible to determine the location of the volvulus. 
When the meteorism is moderate, we may, in the lower abdomen, 
at or to the right of the median line, occasionally palpate a resil- 
ient tumour having the resistance of a tightly distended air cushion. 
The tumour usually extends from the lower left side upward toward 
the right hypochondrium ; there may be tympanitic or metallic 
tinkling on percussion, but there may also be dulness if the sig- 
moid flexure is very edematous, or contains large quantities of faeces. 

Yisible peristalsis is rarely observed. Treves noticed this 
phenomenon twice in 20 cases. Incomplete occlusion is probably 
present in such cases. 

In volvulus of the sigmoid flexure the general condition of the 
patient also suffers ; the reaction, however, is not as severe as in 
obstruction of the small intestine. The pulse remains of good 
quality for a long time, and is not immoderately frequent, the face 
does not bear that collapsed expression (facies hippocratica) that is 
seen, for instance, in strangulation of the small intestine. In one 
of my cases, a woman of sixty-four years, three days after the onset 
of symptoms of obstruction, the patient was able to descend two 
flights of stairs without apparent effort. If diffuse peritonitis or 
perforation occurs, the symptoms very rapidly change. 



420 DISEASES OF THE INTESTINES 

The clinical picture of volvulus of other segments of the large 
intestine, and of the small intestine, is somewhat different from that 
of the sigmoid flexure. For example, in volvulus of the upper por- 
tion of the large bowel, both tenesmus and bloody evacuations are 
absent and the pain extends more toward the back. In volvulus of 
the small bowel, on the other hand, the segment below the point 
of constriction may contain intestinal contents, and these may be 
evacuated. A case described by Naunyn* was characterized by 
the passage of large quantities of unaltered blood. The mete- 
orism naturally is variously localized. A case of Nothnagel's f dem- 
onstrates that the course of the disease is not necessarily violent, and 
may for a time appear favourable. 

Diagnosis 

In diagnosticating volvulus of the sigmoid flexure, the history 
and the subjective and objective symptoms require consideration. 

The history will give valuable data. It informs us regarding the 
existence of long-standing chronic constipation, and perhaps also 
of a former incomplete attack of volvulus of the sigmoid flexure. 

The subjective symptoms to be considered are the pain, the 
vomiting, the complete intestinal obstruction, and the general con- 
dition of the patient. These have all been already described. Col- 
lectively they indicate an intestinal obstruction. The manner of 
their occurrence, which, as already mentioned, is characterized by 
a certain benignancy and slow development, offers serviceable hints 
regarding the nature and the seat of the obstruction. 

The most important objective sign is local tympanites. If well 
developed, if the sigmoid flexure can be differentiated from other 
intestinal coils by auscultatory percussion, if the distended sigmoid 
flexure can be grasped and distinctly palpated, and if the other symp- 
toms above mentioned are present, the diagnosis is generally assured. 
If only small quantities of air or water can be injected into the rec- 
tum, and these are immediately returned, the diagnosis is made still 
more certain. On the other hand, as Treves correctly observes, the 
possibility of large quantities of injected water being retained by the 
lowest bowel segment by no means militates against occlusion of the 
sigmoid flexure. It seems to me important also that injections of 
large quantities of water cannot produce splashing sounds in the 
caecum or transverse colon. In the presence of severe general 

*Loc. cit., p. 110. f Loc. cit., p. 351. 



INTESTINAL OBSTRUCTION 



421 



tympanites the demonstration of splashing sounds in the csecum 
may not be possible, even though the sigmoid flexure be pervious. 

The indican test may be used as a diagnostic aid. Indican, 
if absent, or present only in very small quantities, speaks for ob- 
struction of the large bowel. Free hemorrhagic fluid has some- 
times been found in operations for volvulus, but with marked tym- 
panites its recognition is extremely difficult. 

It is seldom possible to diagnosticate volvulus of the upper seg- 
ments of the lar^e or of the small intestine. 



III. Invagination, Intussusception 

Preliminary Remarks. — Invagination is a condition in which 
a portion of the intestine is pushed or inverted into the lumen of 
that adjoining. Thus, three tubes are telescoped into one another 
(see Fig. 40). The outer tube is termed the intussuscipiens or 
sheath, and the two inner, 
which are generally full of 
folds, the intussusceptum or 
invaginatum. The latter is di- 
vided into the returning (exter- 
nal) and the entering (internal) 
tubes. The entering tube lies 
against the sheath at the 
"neck" of the invagination 
and is continuous with the re- 
turning tube at the lower (free) 
end of the intussusceptum. 
The point of junction of the 
two internal layers is known 
as the apex. Its relation to 
these layers is fixed ; with them 
it always advances farther into 
the intussuscipiens. The mu- 
cous surfaces of the outer and 

middle tubes and the serous surfaces of the inner and middle tubes 
are opposed to each other. The mesentery of the gut is invagi- 
nated with it, and since the mesentery is compressed and dragged 
upon by the outer layer, the intussusceptum becomes concave at its 
mesenteric border, and hence is pulled eccentrically, and not axially, 
toward the intussuscipiens. 

Besides the ordinary forms, double, or more rarely triple, invagi- 




Fio. 40. — Schematic Drawing to illi-strate a 
Simple Intestinal Invagination. 



422 DISEASES OF THE INTESTINES 

nation, occurs. In the former there are five, in the latter seven, intes- 
tinal tubes. It is necessary also to make a distinction between com- 
plete and incomplete invagination. In the incomplete form only a 
single portion of the intestinal wall projects into the lumen. Partial 
invaginations are sometimes found when tumours (generally benign 
in character) drag one or more coats of the intestines after them. 
As observations of Bottcher 9 and Fleiner 50 have shown, invagi- 
nations incomplete at the outset, may finally become complete. 
Several years ago I observed a partial intussusception in a success- 
fully operated case of cancer of the caecum. Besides simple invagina- 
tion, D'Arcy Power, Birch- Hirschf eld, and Thomas have described 
cases in which two intussusceptions were present in different por- 
tions of the bowel. Such a condition is, however, extremely rare. 

From an etiological standpoint we must distinguish two different 
types of invagination : the physiological and the pathological (Noth- 
nagel), or the agonal and the vital (inflammatory) forms (Leichten- 
stern). 

The first variety very probably occurs immediately preceding 
death. At that time one intestinal segment may lose its power of 
contracting before another ; when an adjoining portion of the bowel 
then contracts an invagination of the second part into the lumen of 
that already paralyzed may take place. This form of invagination 
occurs almost entirely in the small intestine. There may be more 
than one such invagination. They occur more frequently in children 
than in adults, and are found both in an ascending and a descending 
direction. They are further distinguished from the pathological 
variety by the fact that the mesentery is never drawn into the in- 
vagination. This form cannot be diagnosticated before death. 

In contradistinction to the above variety, vital or pathological 
invagination — the only form which is of practical importance — is 
generally single and often of considerable size. The invagination 
is almost always in a descending direction (Leichtenstern found only 
8 ascending invaginations in 593 cases), and is constantly accom- 
panied by invagination of the mesentery. 

Intussusception may occur in all segments of the large and small 
intestines, but with very varying frequency. In general, we distin- 
guish invaginatio enterica (small bowel into small bowel), invagi- 
natio ileo-cmcalis (small bowel into large bowel), and invaginatio 
colica (large bowel into large bowel). Special subdivisions are : 
invaginatio ileo-duodenalis, diwdeno-jejunalis, jejtmalis, jejuno- 
iliaca, ileo-colica, iliaca-ileo-colica, colica, colica-rectalis, and rec~ 



INTESTINAL OBSTRUCTION 



423 



talis. The most important variety is invagination of the small into 
the large intestine (see Fig. 41), which, according to Leichtenstern, 
from an analysis of 479 cases, occurs in 52 per cent of cases at all 
ages. During the first year of life the percentage is as high as 
70 per cent. Xext in frequency are iliac (30 per cent; and colic 

R M. 




Pr.v 



■^H 



I, ileum : li. invaginated ileum ; C. ea?cum: B. IT.. mesenteric base: P?\v. vermiform appen- 
dix : Ca. ascending colon. (Taken from the collection of Prof. Langerhans. of Berlin.) 

invaginations (18 per cent). The proportion is different in adnlts, 
for the iliac and ileo-caeeal varieties are of abont equal frequency. 
In invagination of the ileum the lower portion of this part of the 
bowel is usually affected. Colic invaginations are more frequent 
in the descending colon and in the sigmoid flexure than in the 
other portions of the large bowel. 



424 DISEASES OF THE INTESTINES 

Invagination occurs most frequently in childhood. According to 
Leichtenstern, one half of all intussusceptions occur during the first 
decade. In the first year of life, and particularly between the fourth 
month and the end of the first year, invaginations are very frequent. 

Regarding sex, the majority of cases occur in males. The chronic 
forms are found most often between the twentieth and fortieth 
years of life (50 per cent) ; then follows the first decade with a 
frequency of 25 per cent. According to Rafiinesque 51 , in 51 cases 
of chronic invagination, 38 occurred in men and 33 in women. 

At the present day opinions still differ regarding the etiology 
of intussusception. Contrasted with each other are the spasmodic 
(Dance, Cruveilhier, Beriton, Bristowe, Raffinesque, Nothnagel) and 
paralytic theories, the latter upheld mainly by Leichtenstern. Ac- 
cording to the former theory an energetic, circular tetanic contrac- 
tion of an isolated portion of the intestine constitutes the starting 
point of the inversion. This occurs in such a manner " that the 
intestinal segment below and immediately adjoining the spastically 
contracted portion is drawn up over the latter " (Nothnagel). 
Leichtenstern, on the other hand, claims that the bowel segment 
in question becomes paralyzed through certain intercurrent cir- 
cumstances (diarrhoea, ingesta, traumatism, partial peritonitis) ; this 
segment is then everted and becomes invaginated with the enter- 
ing internal contractile bowel lying below. The latter forms the 
vaginal portion of the intussusception. Again, D'Arcy Power 52 , 
who has won renown because of his work in the pathology and 
operative treatment of intussusception, believes that a disproportion 
between the width of the ileum and caecum is the true cause. If 
either congenitally or otherwise the circumference of the caecum 
is considerably increased, a predisposition to invagination occurs. 
The discussion of these hypotheses, which are thoroughly described 
by Nothnagel, Leichtenstern, and Treves, would lead us too far. 
Animal experiments and theoretical considerations incline me to- 
ward the spastic theory. 

The direct causes of invagination, according to the statistics of 
593 cases gathered by Leichtenstern 53 , do not appear to be uniform. 
In 111 apparently healthy individuals the disease began suddenly ; 
in the remaining number of cases the following etiological factors 
were found : intestinal polypi (30 cases), intestinal cancer and stric- 
ture (6 cases), diarrhoea (21 cases), other abnormal intestinal func- 
tions (25 cases), ingesta (28 cases), abdominal contusion (14 cases), 
concussion of the body (12 cases), invagination during preg- 



INTESTINAL OBSTRUCTION 425 

nancy or puerperium (7 cases), ''catching cold" (6 cases), various 
acute and chronic diseases as well as indifferent and doubtful 
factors (66 cases). From these statistics we can only conclude 
that we are absolutely in the dark regarding the real causes of 
intussusception. 

Symptomatology 

The symptoms of intussusception are those of a severe intestinal 
obstruction with all its characteristics. Because of their peculiarity, 
the pain, vomiting, character of evacuations, the condition of the 
abdomen, and the tumour formed by the invaginated bowel, must 
be described in detail. 

/Spasmodic pain, the first and most prominent symptom, gen- 
erally appears quite suddenly — in nurslings while at the breast, in 
older children during play, in adults in the midst of work or per- 
haps at night. From the beginning the pain is usually of an 
extremely threatening character, so that in children collapse or 
convulsions may usher in the disease, while in adults the sever- 
ity of the pain causes the patient to writhe in agony. After 
the initial paroxysm — which is probably caused by incarcera- 
tion of the mesentery — the pain may become continuous, or, 
as is often the case, may cease for one or several hours. Dur- 
ing the intermissions the patient may take some nourishment 
and for a very short time feel comparatively well. The pain 
may cease before death in consequence of paralysis of the pain 
centres, but there are many cases in which the pain continues 
till death. If the acute invagination becomes chronic, the pain 
may take on a marked paroxysmal character, just as has been 
described in intestinal stenosis. The site of the pain depends 
upon the part of the bowel affected, and varies considerably. 
In children it is generally limited to the region of the umbili- 
cus. In adults the pain may be localized in a portion of the 
intestine which corresponds fairly well with the seat of invagi- 
nation; this fact can be of diagnostic importance. The pain 
is generally accompanied by distressing tenesmus. The character 
of the evacuations (to be described later) and the tenesmus may 
at first view present a striking similarity to that of acute dysen- 
tery. The tenesmus is much more severe in children than in 
adults, so that paresis of the sphincters very soon results. The 
higher up in the intestine the invagination the less marked is the 
tenesmus, and vice versa. 



426 DISEASES OF THE INTESTINES 

In childhood, vomiting accompanies the pain from the onset, and 
may very rapidly run through all the various stages (already 
described) up to feculent vomiting. In adults, vomiting is by no 
means as constant as in the other forms of intestinal obstruction. 
It may be absent throughout or may occur at certain intervals, or, 
as in children, it may be very violent and continuous. These vari- 
ous characteristics depend upon the greater or lesser completeness 
of the obstruction, upon the amount of the mesentery invaginated 
and the degree of its compression, and upon the site of the invagi- 
nation. Unfavourable conditions are found in the iliac, ilio-csecal, 
and ileo-colic forms, while invaginations of the large bowel gener- 
ally run a comparatively mild course. As in intestinal stenosis, 
vomiting is least prominent in the chronic forms. 

The character of the evacuations is one of the most important 
objective symptoms. Invaginations are distinguished from most 
other forms of intestinal obstruction in that evacuations do not 
immediately cease, but one or more stools, evidently derived from 
the distal intestinal segment, may be passed after the onset of the 
intussusception. If real stools no longer occur, there may be 
repeated evacuations of blood, blood and mucus, blood and pus, 
or of gangrenous masses. In these cases the tenesmus is apt to 
be very severe. The hemorrhages constitute one of the most con- 
stant symptoms; they are absent in only 20 per cent of acute cases; 
they vary in amount according to the site and extent of the 
invagination. As soon as the process becomes subacute the hemor- 
rhages may cease or temporarily disappear. On the other hand, 
large, gangrenous, putrid pieces of intestine may be passed per 
rectum. In chronic invagination, hemorrhage, although much more 
frequent than in other forms of chronic intestinal stenosis, may be 
entirely, or almost entirely, absent. Rarely is the hemorrhage large 
in amount. The character of the evacuations varies very much in 
chronic invaginations, and scarcely two cases are alike. 

Aside from the tumour the abdomen presents no noteworthy 
changes. Tympanites is rare ; when present, it is not well marked. 
It is least when diarrhoea is present, somewhat more marked with 
absolute constipation, and extensive only when peritonitis super- 
venes. 

Formerly the presence of a symptom known as the " signe 
de dance" was considered important. It was said to consist in 
a depression in the right inguinal region or in the right iliac fossa, 
presumably caused by displacement of the caecum. This symptom 



INTESTINAL OBSTRUCTION 427 

has lost all value after Raffinesque 51 showed that even in chronic 
invaginations — those most favourable for this sign — it is present in 
only about 4 per cent of the cases. 

The invagination tumour is of much greater importance, and may 
even be pathognomonic. It may be palpated through the abdo- 
men, or through the rectum or vagina. It is present in about half 
of all acute cases, but it can be more easily found and palpated in 
chronic cases. The tumour is, however, not palpable with uniform 
frequency in all varieties of invagination. According to Treves, it is 
most often felt in intussusception of the ileo-caecal region and of the 
csecuru, least so in that of the small intestines and in the ileo- colic 
form. The tumour is more clearly demonstrable in children than 
in adults. This is due to the fact that in the former, because of 
the softer abdominal walls, tumours can be more easily felt. As 
Henoch 54 states, even in such favourable cases the tumour. may be 
obscured by distended coils of intestine. The tumour may vary in 
size from a hen's egg to that of the adult forearm. It is smooth, 
moderately hard, of varying consistency, sausage-shaped, and some- 
what curved. The smaller tumours are the more frequent. The 
size of the tumour that can be mapped out by palpation does not 
always correspond to its real extent, for portions may be obscured 
at the flexures of the colon. The tumour is found most frequently 
over the ascending, next over the transverse colon. When lying in 
the ctecal region it indicates an ileal invagination. The invagi- 
nation tumour, like all other intestinal tumours, is characterized 
by relatively great mobility. It is therefore very difficult, from the 
position of the invagination tumour, to correctly diagnosticate the 
original seat and kind of invagination. Provided it is not fixed 
by adhesions, the tumour can be moved from without, sometimes 
even to a very marked degree. It may temporarily disappear, and 
therefore Treves's warning, never to diagnosticate the absence of 
a tumour unless the abdomen is examined during a paroxysm of 
pain, is timely. Examination at the height of an attack of colic 
offers the best opportunity for distinctly palpating the tumour, and, 
at the same time, determining the existence of tetanic intestinal 
rigidity. The latter is rarely found in acute invagination ; in 
chronic forms it is quite readily demonstrable. 

In acute as well as in chronic cases there may be prolapse of the 
invagination tumour through the rectum. It generally occurs in 
acute invagination, and is most frequent in the ileo-caecal and colic 
forms. When prolapsed, it may be directly palpated, and is seen as 



428 DISEASES OF THE INTESTINES 

a hyperaemic or partly gangrenous tumour. Its origin is evident 
by the appearance at one point of the ileo-csecal opening, and next 
to it a second opening, that of the appendix. Simple as is the 
demonstration of a prolapsed invagination tumour numerous errors 
have been made. For instance, invagination tumours have been 
mistaken for prolapse of the rectum, for polypi, or for hemorrhoids, 
and have been excised. Treves reported several remarkable in- 
stances in which, despite these operative errors, cures resulted. 
The reverse has also occurred, viz., that other tumours (a false 
diverticulum, at another time a blood coagulum) have been mis- 
taken for an invagination tumour. Such confusion can generally 
be avoided by careful and repeated examination, particularly under 
narcosis. 

Diagnosis 

Of all forms of intestinal obstruction, acute intussusception offers 
the most favourable opportunities for early diagnosis. 

Among the subjective symptoms we must consider the sudden 
onset in the midst of good health, the immediate occurrence of 
intense pain of a convulsive or intermittent character, and the 
vomiting (by no means so violent as in other forms of obstruction, 
and feculent in only about 25 per cent of all cases). Tenesmus, 
present in about 50 per cent of all cases, is of special diagnostic 
significance. As, of all varieties of obstruction, it is found in 
volvulus of the sigmoid flexure alone, and here relatively seldom, I 
believe that well-defined, tenesmus is one of the most positive sub- 
jective symptoms of invagination. Disturbances of general health 
vary so much according to the age of the patient, the site, the special 
type, and the condition of the invagination, that they need scarcely 
to be considered in a diagnostic connection. 

The most important of the objective signs is the presence of a 
tumour. As already mentioned, a tumour is demonstrable only in 
about one half of the cases. In obscure forms we would strongly 
recommend repeated examinations, particularly during a paroxysm 
of pain. At this time the invagination tumour approaches the ante- 
rior abdominal wall. By careful consideration of the remaining 
symptoms the character of the tumour will scarcely ever remain 
unrecognised. 

If the tumour projects from the rectum, its peculiarities will 
immediately point to the diagnosis. The character of the evacua- 
tions is also a significant and possibly diagnostic phenomenon. Ab- 



INTESTINAL OBSTRUCTION 429 

solute constipation is generally absent. In addition, there is the 
frequency of bloody evacuations, or evacuations consisting of blood 
and mucus, or of pus mixed with gangrenous shreds. As already 
mentioned, bloody evacuations also occur in incarceration and 
strangulation, but the passing of purulent, gangrenous masses is 
typical of acute intussusception. When we suspect intussuscep- 
tion, early examinations of the stools and search for small micro- 
scopical amounts of pus should be made ; such examinations may 
clear up an otherwise obscure clinical picture. For further diag- 
nostic data see chapter on Differential Diagnosis. 

The diagnosis of chronic intussusception is often quite difficult. 
Rafiinesque 51 mentions that in 55 cases collected by him the diag- 
nosis was incorrect in no less than 27. Here, again, pain is the 
most important and occasionally the most valuable subjective symp- 
tom. It is so often markedly intermittent (coliclike) in character 
that it may indeed be taken as the type of colic pain. Accompany- 
ing the pain, intestinal rigidity with all the characteristics of the 
tetanic contractions of intestinal stenosis (see page 356) generally 
occurs. The patients themselves are conscious of this rigidity. 

Vomiting is not a reliable diagnostic symptom of chronic invagi- 
nation. Its frequency and degree vary considerably. The stools 
present nothing characteristic. As Treves * remarks, " the only cer- 
tain feature in the state of the bowels in chronic invagination is 
the feature of uncertainty." Of importance in this connection is 
the experience of Rafiinesque 51 , that diarhcea is present in about 
one half of all chronic cases. I have found no reports in medical 
literature concerning the presence of pus in the evacuations ; such 
a condition is without doubt more rare than it is in the acute form. 

Of the objective symptoms the most important is the invagina- 
tion tumour. "When well marked it is of greater diagnostic value 
than any other symptom. Regarding the nature of the tumour, 
we refer the reader to the section on symptomatology. In chronic 
intussusception the invaginated bowel not infrequently extends to 
the rectum (according to Raifinesque in about one third of the cases) 
and may be felt there. This is rare in the beginning, but more 
frequent in the later stages of the disease. Just as in acute cases, 
meteorism is not well marked, and the course of the affection and 
general condition of the patient present no special diagnostic char- 
acteristics. 

* Loc. cit., p. 100 [English edition, p. 420]. 



430 DISEASES OF THE INTESTINES 



IV. Bending, Kinking, Adhesions, Mesenteric 
Contractions, Compression 

In previous sections we have described those forms of obstruc- 
tion caused by clefts, fenestra, false bands, etc., which may pro- 
duce severe incarceration or strangulation. There is, however, 
another group, more infrequent and clinically less severe, in which 
intestinal obstruction may be produced by isolated peritoneal adhe- 
sions. They are distinguished from the above group in that both 
small and large intestine are affected with equal frequency. The 
same is true of compression of the bowel from without by other 
conditions (e. g., new growths). 

Treves,* who has carefully described these forms of obstruction, 
distinguishes the following varieties : 

1. Obstruction over a Band 

"If several coils of a thin India-rubber pipe, through which 
water was flowing, were thrown over a tightly-drawn wire, the 
lumen of the tube would become more or less completely occluded 
at the spot where the wire was crossed " (Treves). 

Yery similarly we may imagine that if one or more coils of 
intestine are drawn across a taut tissue strand, the intestinal lumen 
will be narrowed. Through irregular peristalsis and partial adhe- 
sion of the coil to the band more favourable conditions for such an 
occurrence are created. Treves discovered only 4 of these cases. 

2. Obstruction from Acute Kinking Due to Traction ujpon an 

Isolated Band or an Adherent Diverticulum 

In this instance a band attached to the bowel so drags upon its 
point of attachment that the intestine is acutely bent at the latter 
point, and is finally completely occluded. This condition is most 
frequently met with in Meckel's diverticulum or in isolated bands 
connected with the ileum. The ileum, because of its short mesen- 
tery, is particularly predisposed to kinking. Owing to its tendency 
to displacements, the large intestine may also become kinked or bent. 

3. Obstruction from Adhesions which retain the Bowel in a 

Bent Position 

The site of these abnormal bands is either the abdominal or the 
pelvic wall or the abdominal organs, as the liver, kidneys, and 

* Loc. cit., p. 100, etc. [English edition (1899), p. 75, etc.]. 



INTESTINAL OBSTRUCTION 



431 



spleen. The etiological factors are traumatism, pelvic peritonitis, 
perityphlitis, incarcerated and reduced herniae, etc. The kinking 
may be single or multiple — a fact to be remembered at laparotomies. 
The kinking may give no symptoms during life, may partially 
obstruct the passage of the faeces, or, in consequence of some exter- 
nal or internal influence, may suddenly cause all the symptoms of 
an acute intestinal obstruction. The forms of intestinal obstruc- 
tion so frequently observed after reduction of femoral herniae are 
striking examples of this variety. 

4. Obstruction by Cleans of Adhesions of Intestinal Coils to Each 

Other 

This may occur both in the small and large intestines. In the 
former it is most frequent with herniae. If, for example, a large coil 
is markedly compressed in the neck of the hernial canal, adhesions 
develop at this point ; after reduction of the hernia these remain. 
Only the portions of the loop that were compressed become adher- 
ent (open loop). In small incarcerated herniae, on the contrary, 
the entire loop of the bowel in question is bound together by adhe- 
sions (closed loop). Similar adhesive bands occur after intestinal 
ulceration with consecutive local peritonitis, or, as Treves specially 
points out, as the result of cheesy degeneration of mesenteric glands. 

Adhesions between coils of the large bowel occur particu- 
larly after displacements or ulcers of this portion of the intestine. 
Displacements have been discussed in detail in a previous chapter 
(see page 255). From these changes in position accumulations of 
faeces occur and catarrhal changes easily develop ; stercoral ulcers 
may result, and cause local peritonitis and adhesions to the adjoin- 
ing part of the bowel or other abdominal organs. 

In recent years Kelling 55 and 'Westphalen M have shown that 
adhesions between the transverse colon and the liver occur and 
cause a number of intestinal disturbances (pain accompanying 
peristalsis). 

5. Obstruction clue to Traction upon the Intestinal Wall by a 

Diverticulum 

Treves has called attention to a stricture which is characterized 
by marked narrowing of the small intestine and by numerous ulcera- 
tions of the mucous membrane above the stricture. Complete intes- 
tinal obstruction may here result from distortion of the bowel wall 
by a diverticulum. 



432 DISEASES OF THE INTESTINES 

6. Narrowing of the Boivel from shrinking of the Mesentery after 

Inflammation 

The affection first described by Virchow under the name of 
peritonitis chronica mesenterialis apparently plays a much greater 
part in the etiology of intestinal obstruction than was formerly sup- 
posed. In one year, for example, Riedel 57 observed no less than 
8 cases resulting from such cicatrization. The usual site of mesen- 
teric inflammation with subsequent cicatricial contraction is the 
sigmoid flexure, where, as already stated, it may lead to volvulus. 
This process also occurs at the caecum, and, as Riedel has recently 
shown, in the mesentery of the small intestine as well as in the 
peritoneum of the posterior abdominal wall. Besides volvulus of 
the sigmoid, mesenteric contraction causes a displacement through 
traction of some part of the intestines and disturbances of intesti- 
nal mobility ; such disturbances may present the picture of chronic 
bowel stenosis, or in extremely severe cases they may lead to acute 
intestinal obstruction. 

7. Compression of the Bowel from Without 

This term, in its narrowest sense, means the pressure produced 
in an intestinal segment by a body adjoining it ; such pressure 
either narrows or completely obliterates the intestinal lumen. Com- 
pression is generally caused by malignant or benign neoplasms, 
which may belong to the most varied organs (stomach, intestines, 
liver, pancreas, spleen, kidney, lymph glands, mesentery, pelvic 
bones, uterus, ovaries, etc.). A tumour originating in the intestines 
may compress a neighbouring segment. 

Besides neoplasms, other pathological conditions may compress 
the bowel from without ; for example, a retroflexed uterus, large vesi- 
cal calculus, peri- and paratyphlitic abscesses, floating spleen and 
floating kidney, tumours of the pancreas from hemorrhage or 
cysts, etc. 

Owing to its situation, the rectum is most often pressed upon, 
usually by pelvic tumours. According to Leichtenstern, this occurs 
in 60 per cent of all cases. Then follow in order of frequency the 
sigmoid flexure, descending colon, the lower portion of the ileum, 
duodenum, and, finally, the ascending colon and hepatic flexure, 
middle portion of the ileum, and transverse colon. 

In this connection it is important to remember the peculiar 
compression of the small intestines (duodenum or ileum) recently 



INTESTINAL OBSTRUCTION 433 

described by Sclvnitzler 58 . It is produced by the mesentery of coils 
of the small intestine which have descended into the pelvic cavity. 
In a similar manner, from traction of the pylorus in consequence of 
extreme gastrectasia and by compression of the duodenum and other 
portions of small intestine, the clinical picture of acute incarceration 
may be produced (L. Meyer 59 ). 

Symptomatology and Diagnosis 

The clinical symptoms of the above forms of intestinal occlu- 
sion possess, on the one hand, the character of stenosis, and, on 
the other, that of obstruction, and both conditions may suddenly 
or slowly interchange with the other. The few differential diag- 
nostic signs described in the literature of the subject are not suffi- 
cient to distinguish these forms from other similar ones. "We 
shall therefore not give any detailed account of them. Aside 
from several marked instances (obstruction after hernial reduc- 
tion), one fact deserves mention — the course of the disease is gen- 
erally milder and slower than the forms previously described. 

Under certain conditions the diagnosis of these affections may 
be made, i. e., where the cause of the occlusion is visible or pal- 
pable (e. g., tumours, palpable adhesions), or where the history 
points directly to the nature of the disease (obstruction following 
hernial reduction, local peritonitis following traumatism, appendi- 
citis with adhesions, previous operations, etc.). The fact that these 
forms of obstruction affect adults rather than children, and also 
that, as above stated, the symptoms are generally less severe than 
in strangulation, incarceration, or volvulus, may sometimes possess 
diagnostic importance. The exceptions are so numerous, however, 
that in a given case the last-mentioned data must be cautiously 
taken into account, 

V. Internal Intestinal Stricture 

Internal strictures are produced by ulcerations with consequent 
cicatricial contractions, by cancerous strictures, and by inflammatory 
(hypertrophic) conditions of the intestinal wall. 

The ulcerations to be considered are the tubercular, stercoral, 
dysenteric, typhoid, and syphilitic. Tubercular ulcers are among 
the most frequent causes of intestinal stricture ; the other forms 
have little practical importance. As is well known, syphilitic 
ulceration is most frequent in the lowest portions of the bowel, 
especially in the rectum, and is extremely rare in the upper por- 



434 DISEASES OF THE INTESTINES 

tions of the intestine. Strictures due to previous ulcerative pro- 
cesses also occur in incarcerated herniae and after traumatism. 
Finally, the peculiar strictures accompanying pernicious anaemia, 
to which Knud Faber 20 has recently called attention, must be men- 
tioned. 

Cancerous ulcerations are mainly found in the large bowel and 
rectum ; they are characterized by a tendency to the formation of 
stricture. Since ulcerations, neoplasms, and their sequelae have 
already been discussed in a separate section, a detailed account of 
these affections will not again be necessary. 

Symptomatology and Diagnosis 

As regards the intestinal stricture or obstruction, the symp- 
tomatology is the same as that described in the previous section. 
Special symptoms, when present, are evidenced by the special 
form of the underlying disease (tumour, syphilis, tuberculosis, dys- 
entery, etc.). 

This is true also of the diagnosis. Where constitutional changes 
or a characteristic tumour point directly to the cause of the affec- 
tion, the correct diagnosis can be made ; in other cases it may 
only be possible to say that there exists a stricture or total occlu- 
sion, or perhaps to determine approximately the portion of the 
bowel affected. 

In stricture of the small intestine we should, on account of its 
frequency, first suspect tuberculosis as the probable cause. In 
stricture of the large intestine, exclusive of the caecum, we must 
think of cancer. Syphilitic stenoses and stenoses due to sclerotic 
changes in the submucosa can not, in the present state of our knowl- 
edge, be positively diagnosticated. 

VI. Obstruction from Foreign Bodies 

In this category are included gallstones, intestinal concretions, 
instruments introduced per os or per anum, and inspissated fasces. 

(a) Obstruction by Gallstones 

This may occur in all parts of the intestinal canal from the 
pylorus to the rectum, but the different segments are not affected 
with equal frequency. Those most frequently involved are the 
lower portion of the ileum and the ileo-caecal valve — i. e., the 
divisions which, for anatomical reasons (narrow lumen of the lower 



INTESTINAL OBSTRUCTION 435 

ileum, short taut mesentery), offer most resistance to the passage 
of large stones ; next in frequency are the duodenum and jeju- 
num. Obstruction by gallstones is rarer in the upper or mid- 
dle portions of the ileum, and is extremely rare in the colon and 
rectum. In the vast majority of cases the stone passes into the 
intestine through a fistula which has resulted from inflammatory 
adhesions between the gall bladder and the intestines. Commu- 
nication between gall bladder and duodenum is the most fre- 
quent occurrence, while that between small intestine and colon is 
rarer. Stones have been known to enter the duodenum through 
a choledocho - duodenal fistula. Gallstones may cause intestinal 
obstruction in other ways. Thus, Mikulicz 60 twice found gall- 
stones, not in the intestinal canal, but in diverticuli of the cystic 
duct which lay across and compressed the duodenum. The obser- 
vations of J. Israel 42 and Korte 62 have shown that smaller stones 
may produce intestinal obstruction, probably by exciting circular 
spastic contraction of the bowel. When a stone has been impacted 
for a long time, and is large and angular, it may produce inflamma- 
tion and swelling of the intestinal wall, or even gangrene and peri- 
tonitis with or without perforation. 

Symptomatology 

It is well known that obstruction by gallstones is met with 
more frequently in women than in men. Regarding age, 
Naunyn 37 has found among 120 cases only 5 under the age of 
thirty, and only 7 between thirty-one and forty years of age, 
while there were 96 cases between the ages of forty-one and 
sixty. After the latter period there is again a decided decrease 
in frequency. 

In many cases (according to Lobstein 62 17 times in 90) there 
is a previous history of attacks of biliary colic, or more rarely 
of jaundice. It is important to inquire whether the patient has 
suffered from paroxysmal attacks of so-called " stomach ache," 
which, as a rule, are nothing more than ill-defined attacks of chole- 
lithiasis. 

In other cases the history may point to a local peritonitis as the 
cause of the rupture into the intestines, or only a doubtful connec- 
tion can be established. 

The symptoms of intestinal obstruction vary widely according 
to the location of the stone. As already mentioned (page 316), the 
stone, when situated high up in the duodenum, produces symptoms 



436 DISEASES OF THE INTESTINES 

of pyloric stenosis ; in the descending portion of the duodenum con- 
tinued bilious vomiting is one of the characteristic symptoms ; still 
farther down, the usual symptoms of obstruction of the small intes- 
tines occur — reflex vomiting, which may very soon become fecu- 
lent or even faecal, visible or palpable intestinal peristalsis, more or 
less (generally less) meteorism, and finally retention of stool and 
gases. Naunyn ° 7 , the greatest authority on cholelithiasis, observes 
that in intestinal obstruction by gallstones the retention of stool and 
flatus is not necessarily absolute. Collapse soon follows ; it is sel- 
dom of the severe type met with in other forms of intestinal obstruc- 
tion. In unfavourable cases death occurs between the fifth and tenth 
days of the disease, rarely later. There may be a favourable ter- 
mination if the stone has been forced through the narrowest part 
of the gut — that is, if the stone has passed into the large intes- 
tine ; here, however, it may remain for days before it is passed 
per anum. On the other hand, a cure does not result in all cases 
in which the stone has been passed. An intestinal lesion may 
remain which may later produce death from perforative peritonitis. 
Not rarely, as Naunyn 37 states, the lumen of the bowel may only 
temporarily remain pervious, and after days, or even weeks, again 
become obstructed. Finally, two attacks of obstruction by gall- 
stones have been observed in the same individual. Reports show 
that if there be a fistulous communication between the gall blad- 
der and colon, large stones may pass without causing symptoms of 
obstruction. 

Diagnosis 

In diagnosticating obstruction from gallstones it is necessary to 
determine that there really is a calculous obstruction, and, if pos- 
sible, the site of the stone. In favourable cases (i. e., where the 
obstruction is situated high up) when evidences of former chole- 
lithiasis or of a communication of the gall passages with the upper 
intestinal tract are present, it is possible to establish both the above 
facts. If the history is not reliable, and if objective signs of pre- 
vious cholelithiasis (enlargement of the liver, painful gall blad- 
der, and pressure sensitiveness of the posterior portion of the liver) 
are absent, a probable diagnosis may be made by exclusion. We 
must remember that incarceration, strangulation, volvulus, perito- 
neal adhesions, and internal stricture of the upper part of the in- 
testinal canal (duodenum, jejunum) are relatively rare. Mistakes 
cannot, however, be avoided. If the stone is impacted lower down 



INTESTINAL OBSTRUCTION 437 

in the bowel, the diagnosis may be easy when a well-defined history 
is obtained, or when characteristic changes about the liver or gall 
bladder are found. In all cases of intestinal obstruction, there- 
fore, one should carefully examine and palpate the liver and gall 
bladder. 

Yery rarely a tumour is palpable on the left or right side 
of the abdominal cavity (Kirmisson-Rochard ", Sick 64 , Kostlein 65 , 
Dessauer m ). Maclagan 67 has observed two cases in which a pain- 
ful tumour was felt in the neighbourhood of the liver, and when 
this tumour disappeared symptoms of intestinal obstruction gradu- 
ally developed. If none of the above-mentioned data can be 
obtained the differential diagnosis from other forms of intestinal 
obstruction will be difficult. When there is a suspicion of obstruc- 
tion from gallstones repeated rectal and vaginal examinations should 
be made, for gallstones have thus been demonstrated in the intes- 
tines. Gallstones in the rectum may be digitally or instrumen- 
tally removed. 

Visible intestinal peristalsis may make possible the localization 
of the obstruction, but it can seldom be observed, and is also found 
in other forms of intestinal obstruction. 

As previously mentioned, the large intestine is rarely occluded 
by gallstones (1 case of Korte 61 and 2 cases of Courvoisier 68 ). 
This may, however, occur in the rectum, when the peculiar symp- 
toms (tenesmus, obstinate constipation, pain) will direct immediate 
attention to the site of the trouble. 

(b) Obstruction by Enteroliths 

We have already described the different varieties of intestinal 
concretions (page 112). They generally originate in the large 
intestine, for in this situation conditions are most favourable for 
the development of hard concretions. They are chiefly situated in 
the haustra coli or in the rectal ampulla. In the small intestine 
concretions due to stagnation of the contents may develop in the 
so-called true or false diverticula They occur most often in young 
persons, and particularly in the poorer classes who subsist mainly 
onVegetables, rather than in the better classes, whose diet contains 
more animal matter. Intestinal concretions form very gradually. 
" They may, moreover, be dormant, as it were, for years, or excite 
during that time but insignificant symptoms " (Treves).* 



* Loc. cit., S. 336 [and Intestinal Obstructions, page 199]. 
29 



438 DISEASES OF THE INTESTINES 

Symptomatology 

The symptoms of this variety of obstruction resemble those of 
chronic stenosis, viz., constipation, attacks of vomiting, paroxysms of 
pain, and disturoances of general health. In a few cases large con- 
cretions have been felt through the abdominal walls or through the 
rectum. Occasionally fragments have been passed with the stools. 
By reason of its powerful muscular coat and its elasticity, the large 
intestine permits of the passage of very large concretions ; hence 
severe symptoms of obstruction have very rarely been observed 
(case of Down 69 ). Where the concretion is retained in the caecum 
it may produce all the symptoms and sequelae of typhlitis or peri- 
typhlitis. 

Diagnosis 

A positive diagnosis of an intestinal concretion can only be 
made when the concretion can be felt pe* rectum. The diagno- 
sis is perhaps most likely to be made when a tumour is palpable, 
when symptoms of partial obstruction are present, when the gen- 
eral condition of the patient and the very protracted course of 
the affection speak against carcinoma, and when the customary 
food of the patient has been such as to favour the formation of 
concretions. 

(c) Obstruction from Entozoa {Ileus Verminosus) 

Opinion is still divided as to whether entozoa (chiefly ascarides) 
may cause intestinal obstruction. Leichtenstern \ Davaine 70 , and 
Heller 71 doubt its occurrence, while Mosler and Peiper 72 answer 
the question in the affirmative. In his Bibliographie d. klinischen 
Helminthologie, Huber cites 13 cases of obstruction caused by a 
large accumulation of ascarides in the intestines. It occurs almost 
exclusively in children. The ileo-caecal valve is said to be the main 
site of the occlusion. Whether the obstruction is of a mechanical 
nature, or whether, as seems more probable, it is dynamic (reflex) 
in character, is as yet undecided. In the vast majority of cases the 
disease runs an unfavourable course. Heidenreich re has reported a 
successful case of enterostomy and Simon 74 one of colostomy for 
this condition. Yery few of the observations heretofore made will 
stand critical examination ; it is therefore impossible to describe the 
characteristic symptoms. The diagnosis is only possible through 
the accidental evacuation of ascarides, which is usually a result of 
therapeutic measures. 



INTESTINAL OBSTRUCTION 439 

(d) Obstruction by Foreign Bodies which have been Introduced 

Foreign bodies that have been purposely or accidentally intro- 
duced may reach the intestines through the mouth or anus. Most 
remarkable bodies have thus found their way into the intestinal 
canal. Neurotic patients have swallowed very dangerous arti- 
cles, frequently with suicidal intent, but occasionally also when 
mentally deranged. Both old and recent literature is replete with 
such instances, which are simply medical curiosities and hence 
need only be mentioned. We refer, however, to the recent thor- 
ough article of Frikker 75 , who describes a unique case which oc- 
curred in his own practice. Coins and similar articles, or false 
teeth, are most frequently swallowed. 

Symptomatology 

If their size or length is not disproportionate to the lumen of 
the intestinal canal, swallowed articles generally pass through the 
bowels without trouble. This is also true of pointed or sharp 
bodies (nails, files, needles). In the majority of instances their 
expulsion is painless, and cause no symptoms of any kind. 

If the foreign body is not passed, it is apt to be retained in 
certain portions of the alimentary canal — the stomach, lower 
segment of the ileum, duodenum, and more especially the caecum 
and ampulla recti. Even then symptoms are not necessarily pres- 
ent; they may appear only after the expiration of months or 
years. There may be pain, colic, vomiting, more or less complete 
constipation, ulceration of the mucous membrane with perforative 
or local peritonitis, or with resultant stricture or abscess opening 
externally. After having passed through the intestinal wall, nee- 
dles may be carried to different parts of the body, and extrude 
spontaneously or be artificially removed. 

Diagnosis 

The diagnosis of swallowed foreign bodies can be made either 
from the history or from direct evidence. Regarding bodies intro- 
duced into the rectum direct evidence should by all means be 
obtained. In all other intestinal segments such evidence is only 
exceptionally obtainable by palpation. Metallic foreign bodies are 
best demonstrated and located by radiography. 

My experience has shown that patients often imagine they have 
swallowed articles (needles, false teeth, etc.). I once " removed " 



440 DISEASES OF THE INTESTINES 

a needle — presumably swallowed — from a hysterical female by show- 
ing her a needle in the water of an enema. 

(e) Obstruction from Fcecal Tumours 

In marked habitual constipation accumulations of faecal matter 
may obstruct the lumen of the bowel. These tumours occur only 
in the large intestine, and particularly where the faeces are apt 
to be retarded — i. e., in the caecum, at the flexures, and especially 
the sigmoid flexure. The longer the faecal mass is retained, the 
greater is its loss in water and its chances for increase in size from 
further faecal accumulation. Notwithstanding, these masses only 
exceptionally produce total obstruction, for there is always suffi- 
cient space for fluids and semisolid faeces to pass between the 
tumour and the intestinal wall. 

Obstruction of the kind just described may produce other and 
occasionally serious consequences. The frequent development of 
sigmoid volvulus from impaction has already been mentioned. 
Furthermore, as described in the section on Cancer of the Large 
Intestine, a faecal mass may be impacted in front of a stenosis in 
such a manner as to directly cause intestinal obstruction. As a 
result of stagnation of faeces, there may be a descent of intestinal 
coils, especially of the movable transverse colon, with consequent 
kinking or the formation of stercoral ulcers, and, in extreme cases, 
as a result of exhaustion of the muscular coat of the bowels, there 
may be complete arrest of the faeces. (See Ileus Paralyticus.) 

Symptoms 

These are mainly those of chronic partial or complete intes- 
tinal obstruction. Some differences arise from the varying situa- 
tions of the faecal tumour. Thus, when situated low down (sigmoid 
flexure, rectum) there is tenesmus ; when higher up the latter is 
absent. The most important symptom is the faecal tumour itself, 
whose special peculiarities have been discussed in the General 
Division. 

Diagnosis 

It is usually easy to recognise faecal tumours in the lower por- 
tion of the large intestine by abdominal, rectal, or vaginal palpa- 
tion. If the mass is situated in the upper portion of the large 
bowel, the diagnosis is more difficult, particularly when meteorism 
obscures the tumour. In such cases the history and clinical course 



INTESTINAL OBSTRUCTION 441 

alone, more especially, however, repeated observations of similar 
more or less severe attacks, may lead to the correct diagnosis. 
Even here, however, there must always be a lurking suspicion of 
some organic hindrance, of incomplete or beginning volvulus, peri- 
toneal adhesions, kinkiugs, or compressions. It is still more diffi- 
cult to decide whether the palpable faecal tumour is the cause or 
result of the occlusion. Only complete, permanent relief from all 
the symptoms warrants a good prognosis. 

VII. Obstruction without Physical Changes in the Intestines 
(Paralytic, Spastic, and Dynamic Obstructions) 

Besides intestinal obstruction from mechanical hindrance, there 
is a second form in which the symptoms of obstruction are pres- 
ent without any discoverable cause. The older practitioners rec- 
ognised this seemingly paradoxical condition. In 1865, Henrot, 
in a thesis classical even at the present time, gave an exhaustive 
description of these pseudo-etrangleinents. 

The conditions are most readily understood when the intes- 
tines have been injured in some manner — e. g., by severe trauma- 
tism or continued constipation or abnormally great meteorism. At 
present we are unable to explain the origin of a sudden severe 
intestinal paresis. It may be theoretically explained, however, 
that there are marked changes in the innervating fibres of the 
muscular coat of the bowels, and that these changes cause the 
paresis. In other cases the paralysis is evidently due to reflex 
action (the paralysie reflexe of the French). A classic instance is 
that of the undescended testicle, which, when inflamed, may cause 
symptoms of intestinal obstruction ; or, as recently demonstrated 
by numerous examples, an operation has been performed on the 
intestines, uterus, or ovaries, and there develops severe intes- 
tinal obstruction without any discoverable lesion in the intestinal 
wall itself. Whether the dynamic intestinal obstruction often 
found in peritonitis, and particularly in perityphlitis, is reflex, or 
whether, as Stokes maintained, it is caused by a serous infiltra- 
tion of the bowel wall (collateral oedema), in which case modern 
writers would claim toxins as etiological factors, or finally, whether 
it is produced by lessened absorption (and hence accumulation) 
of gases, is a question which cannot at present be answered with 
certainty. 

Based upon several observations, Leichtenstern 26 has proposed 
another theory to explain the intestinal paralysis of peritonitis. 



442 DISEASES OF THE INTESTINES 

According to this author, when the patient is lying on his back 
those distended intestinal coils which have long mesenteries are 
lifted up by the gases in them and pressed toward the ante- 
rior abdominal wall, while coils with fluid contents, particularly 
those with short mesenteries, cannot move or can move but little 
from the vertebral column. Because of their weight, the stagnant 
fluid contents of the duodenum or jejunum are much more likely 
to flow back into the stomach than they are to pass into the dis- 
tended, paralytic bowel, which lies higher up and is held in place 
by the meteorism. This explanation, however, is sufficient only 
for isolated cases, since the above condition is absent in many cases 
of peritonitis with marked tympanitis. 

Spastic obstruction {ileus spasmodica) is a second form of 
dynamic ileus, and one whose importance has only lately been 
acknowledged. 

In spastic ileus there develops in any portion of the intes- 
tines a " spastic obstruction " which may be followed by the same 
changes as a mechanical obstruction. Heidenhain 76 , by his vivisec- 
tion experiments, has again brought this subject into prominence. 
Spastic obstruction occurs under the most widely different condi- 
tions : as primary spastic obstruction without discoverable cause, 
as a complication of hysteria (very remarkable instances have re- 
cently been described by von Leube w and Strauss), in gallstone 
obstruction without mechanical intestinal occlusion (J. Israel 42 , 
Korte 61 ), as a reflex condition in mechanical ileus (Heidenhain), 
in crises gastriques (Sandoz 78 ), in tubercular intestinal ulcerations 
(Strehl 79 ), and with foreign bodies in the rectum which do not 
entirely close its lumen (Grundzach 80 ). The case described by 
the last-mentioned author appears to me to be an especially good 
example of spastic intestinal obstruction ; I shall therefore briefly 
describe it : 

After eating a hearty supper a man, thirty years of age, complained of ab- 
dominal pain, tenesmus, constipation, absence of flatus, and anorexia. Castor 
oil and calomel were given without result. Stomach and intestines markedly 
distended ; abdomen sensitive to pressure ; face anxious. Beginning intestinal 
obstruction was suspected. Rectal examination discovered a fishbone, 5 to 6 
centimetres long, lying crosswise in the rectum. After extraction of the bone 
the patient very soon passed flatus and fluid stools. 

Leichte astern 1 is of the opinion that the intestinal spasm is 
simply a persistence of the muscle in a condition of elastic tension. 



INTESTINAL OBSTRUCTION 443 

Nothnagel * also considers this possible. There are cases (for exam- 
ple, the one just described, and that of gallstone obstruction with- 
out occlusion) which point more conclusively to a spasmodic con- 
dition than to one due to intestinal paralysis. From a practical 
standpoint, however, both conditions are the same. 

Symptomatology 

The clinical picture of functional intestinal obstruction is so 
very similar to that of the various forms of mechanical obstruction 
already described, that we should only have to repeat what has 
been said. From this it will be seen that a demonstrable and ob- 
jective differentiation between these two general forms is very diffi- 
cult. It might be stated that visible peristalsis is absent in func- 
tional occlusion, but then it is also quite often absent in mechanical 
ileus. 

Diagnosis 

Under the above circumstances the diagnosis is extremely diffi- 
cult. This is appreciable when, for example, we have to differen- 
tiate between peritonitis with intestinal paralysis and mechanical 
obstruction. In the introductory part of this chapter (page 368) 
we have described the factors that have to be considered. When 
there are symptoms of obstruction after operations upon the intes- 
tines or the sexual organs, or after reduction of a hernia, the con- 
ditions may be so favourable that a correct diagnosis is possible. 
Everybody who is acquainted with the literature of this subject 
knows that diagnostic errors are very apt to be made, for it will 
scarcely be possible to exclude apparently insignificant mechanical 
causes (slight adhesions, circumscribed peritonitis, intestinal com- 
pression, and crushing). For these reasons many surgeons are 
sceptical regarding dynamic obstruction. 

Differential Diagnosis between the Several Forms of 
Intestinal Obstruction 

In the majority of cases it is impossible to make a correct diag- 
nosis of the variety and localization of the obstruction. In prac- 
tice we must often be contented when we have approximately 
determined the site of the lesion and the probable cause of the 
occlusion. 

The first question to be determined is whether the obstruction 

* Loc. cit., S. 360. 



444 DISEASES OF THE INTESTINES 

is in the large or the small intestine. In what follows, therefore, 
we shall briefly describe the symptoms which indicate the localiza- 
tion of the obstruction in one or the other parts of the intestinal 
tract. 

(a) Small Intestine. — Here objective signs to a slight degree, 
but more especially the knowledge gained from experience, aid in 
making the diagnosis. Experience may be of great service. We 
herewith give an example : Sudden intestinal obstruction occurs in 
a young man who has always been well. ~No hernia ; very rapid, 
extremely acute development, with vomiting soon becoming faecal ; 
no flatus or stool passed ; intense indicanuria from the very onset 
of the disease ; no marked meteorism. In such a case we may, 
without fear of error, diagnosticate obstruction of the small bowel. 
A second example is the following : An elderly woman, well except 
for obstinate habitual constipation, is attacked with symptoms of 
slight obstruction. No stool or flatus passed, slight vomiting, not 
fsecal in character ; marked localized meteorism ; marked tenesmus. 
Here we need have no great hesitation in diagnosticating an obstruc- 
tion of the large bowel, probably a sigmoid volvulus. 

No doubt there are cases in which from the very onset the symp- 
toms are so obscure that the diagnosis of the site of the lesion is 
only a matter of personal experience, or rather of personal equation. 
Regarding such doubtful cases, it must be mentioned that occlusions 
of the large bowel generally present better objective signs than those 
of the small bowel. Rectal injections or inflation, recognition of a 
large, fixed, distended intestinal coil by means of auscultatory percus- 
sion, the possibility of palpating this intestinal coil, the previously 
described lumbar symptoms of N othnagel (page 355) ; the recogni- 
tion of mild peristalsis — all these combined will in favourable cases 
lead to comparatively certain conclusions. It has often been men- 
tioned that examinations per rectum and vagina, and of the evacua- 
tions, may yield important, and, under certain circumstances, deci- 
sive results. Error is unavoidable in those apparently rare cases 
of simultaneous obstruction of both large and small intestines, de- 
scribed by Treves in his monograph, and lately, after several opera- 
tions, by Hochenegg 81 (combination ileus). Furthermore, as already 
mentioned, the occurrence of multiple invaginations, cicatricial stric- 
tures, peritoneal adhesions, volvuli, etc., should be remembered. Such 
conditions cannot be recognised during life. 

After the local diagnosis has been made other difficulties must be 
overcome. We can, however, often reach a diagnosis by exclusion. 



INTESTINAL OBSTRUCTION 445 

The differential diagnosis of the nature of the obstruction must 
necessarily be limited to those conditions which are at all capable 
of being diagnosticated. Hence we must exclude constriction by 
omental bands, incarcerations by the appendix or by Meckel's diver- 
ticulum, by pseudo-membranes, fenestra or clefts in the mesen- 
tery, or by adhesions of several intestinal coils ; occlusion by kink- 
ing or distortion, by the formation of knots, volvuli (excepting sig- 
moid volvulus) ; internal hernise (with the possible exception of 
diaphragmatic hernia). We do not wish to imply that the diag- 
nosis of these forms of obstruction can never be made, but that 
they can be recognised only under particularly favourable and 
rather accidental circumstances. 

Deplorable as this is, it enables us to restore order out of this 
diagnostic chaos, by allowing us to study more carefully the few 
recognisable and distinguishable varieties of obstruction. For this 
purpose a detailed history, a careful study of the patient's condi- 
tion, and an accurate knowledge of the symptomatology of intes- 
tinal obstruction are necessary. 

As G-raser 82 states, the history and the patient's daily condition 
should always be noted in writing, and any changes should be 
compared with previous observations. If careful observation at 
home is not possible, doubtful cases should immediately be sent to 
a suitable hospital. 

Naunyn rightly observes that in all forms of intestinal obstruc- 
tion the first practical question is whether or not an incarceration 
or a strangulation is present. In not a few instances this ques- 
tion may be answered affirmatively because of the severe initial 
symptoms — violent shock, almost constant intestinal pain, early 
vomiting soon becoming faecal, and collapse very rapidly reaching 
the greatest possible severity. The important objective symptoms 
of incarceration and strangulation are the distended, fixed intes- 
tinal coil (occasionally with peristalsis), hemorrhagic exudate into 
the dependent portion of the abdomen, meteorism, moderate or 
absent, large intestinal hemorrhages (rare) (Naunyn), and marked 
indicanuria from the beginning of the disease. The first symp- 
tom (von Wahl's) is the most important, but unfortunately it is 
not always well marked. As previously mentioned, it is entirely 
absent when the strangulation affects a large part of the intestine. 
In such cases it is impossible to diagnosticate more than the site 
of obstruction, ^othnagel's case (mentioned on page 382) shows 
that there are exceptions even to these rules. 



446 DISEASES OF THE INTESTINES 

Among the forms of obstruction of the small intestine that can 
be diagnosticated we must consider obstruction by gallstones. The 
facts that are of value for the diagnosis of doubtful cases — and these 
alone are here considered — are the age of the patient (generally over 
thirty-one years), sex (more frequent in the female), the history 
(which may, however, leave us entirely in the dark), some change 
(though but slightly indicated) in the liver, especially the pro- 
tracted course, the passing of flatus, and, despite faecal vomiting, of 
stool, and, finally, the slight tympanites. Hemorrhages per anum 
do not speak against gallstone obstruction. When the obstruction 
is situated high up — i. e., in the vicinity of the papilla — the picture 
is in itself very characteristic, although the cause of the occlusion 
may remain obscure if the history does not contain data which 
call attention to the possibility of intestinal obstruction by a gall- 
stone. The case might, however, be one of obstruction due to 
compression by neighbouring tumours (which need not necessarily 
be palpable), by adhesions with surrounding tissues (gall bladder, 
pylorus, mesentery, etc.), by ulcers with cicatrization (Yarr), and 
by torsion of the mesentery (J. Schnitzler). 

Foreign bodies impacted in the small bowel can be diagnosti- 
cated only when there is a history of their having been introduced ; 
otherwise this is not distinguishable from other forms of obstruc- 
tion, especially that by gallstones. 

(b) As already mentioned, obstructions of the large intestine are 
more readily recognised and their nature determined than are ob- 
structions of the small intestine. There is less danger of an error 
in intussusceptiou than in any other form. Its occurrence in very 
young children, its sudden onset, the severe but generally intermit- 
tent pain, the tenesmus, the characteristic discharges (especially the 
admixture of pus and blood), the presence of a smooth, growing, and 
wandering tumour which occasionally becomes tetanically contracted 
and is sometimes directly palpable and visible per rectum, in some 
cases the passing of a sloughing, gangrenous intussusception — all 
these symptoms, taken together or separately, are so characteristic 
that doubt as to the correct diagnosis can occur only under partic- 
ularly unfavourable circumstances. In the differential diagnosis we 
must consider rectal polypi with bloody stools (which are, however, 
easily distinguished from invaginations), acute dysentery, and severe 
intestinal colic. In the early stage of the disease it ' is sometimes 
impossible to distinguish the latter condition from intussusception, 
but the diagnosis is almost always cleared up by the further course 



INTESTINAL OBSTRUCTION 44.7 

of the affection. On the other hand, it is usually impossible 
to correctly diagnosticate an invagination accompanied by a neo- 
plasm. 

Generally, volvulus of the sigmoid, the second most frequent 
form of obstruction of the large bowel, also presents a character- 
istic picture. Its main diagnostic features are the occurrence late 
in life and in persons suffering from obstinate constipation, the 
sudden development combined with a relatively slow course, ab- 
sence of faecal vomiting despite complete intestinal obstruction, 
futility of rectal injections of large quantities of water* (less 
than one half litre), marked meteorism, which may extend over 
the whole abdomen or may become quite visible and be limited 
to a fixed coil, but without peristalsis, frequent tenesmus, and 
finally slight indicanuria. Bloody evacuations occur in volvulus 
of the sigmoid flexure as well as of the small intestine, in in- 
vaginations, and but rarely in obstructions from gallstones. The 
other symptoms vary so widely that only rarely ought there to be 
any difficulty in differentiating between these conditions. We 
may, however, have to determine whether we are dealing with a 
simple volvulus, or with a volvulus produced by a carcinomatous 
stricture or a tumour. When a tumour is absent, it will generally 
be impossible to make the differentiation. In itself the clinical 
picture is not sufficiently characteristic to enable us to state whether 
we are dealing with a complete volvulus of 360 degrees or with 
one of 180 degrees. 

Occlusions of the large intestine which develop in the later 
stages of a stricture (generally carcinomatous or tubercular) are also 
easily recognisable. If a tumour is present, there can only be doubt 
as to its nature ; frequently the further course of the disease will 
clear up the case (compare chapter on Intestinal Neoplasms). If 
there is no tumour, we can arrive at more than a probable diag- 
nosis only in the presence of other definite clinical data — tuber- 
cular symptoms, pyrexia, age, metastases, cancer cachexia, etc. 
Usually it is impossible to determine whether the obstruction is 
caused by paralysis of the intestinal wall, or by foreign bodies or 
feces impacted in front of the stenosis, or by other mechanical 
factors. 

Foreign bodies in the large intestine which have been swallowed 
can be diagnosticated from the history ; others can only be recog- 

* Compare, however, limitations, given on page 382. 



448 DISEASES OP THE INTESTINES 

nised when found in the rectum, or when fragments of them are 
accidentally passed per rectum. Of importance, too, is the fact that 
enteroliths are generally found in the caecum, and produce symp- 
toms of typhlitis or intestinal stenosis before the symptoms of 
obstruction appear. Occasionally a tumour may be felt in the 
caecum, but its nature will be doubtful. On the whole, however, 
enteroliths will seldom have to be considered in the differential 
diagnosis. 

As mentioned in the general division (p. 76), fazcal tumours of 
the large bowel have often given rise to error. One who has had 
any experience with these pseudo-tumours will, I believe, scarcely 
ever be misled. Even when these tumours consist of old residua, 
their compressibility and elasticity will usually indicate the proper 
diagnosis. Difficulty will only arise when, in addition to the faecal 
tumour, a real neoplasm is present, or when the clinical course 
points to a neoplasm. The case taken from Nothnagel's Diseases 
of the Intestines, and cited on page 77, is a very good example of 
this. For the diagnosis of a faecal tumour, the clinical course is 
very important, and the history may give us valuable information. 
Faecal tumours produce symptoms of occlusion very gradually, and 
these, when present, are relatively mild. The general health is but 
little affected ; there is absence of faecal vomiting, of a fixed dis- 
tended intestinal coil (a point of differentiation from volvulus of the 
large intestine), and of visible peristalsis. This latter condition is 
always present in stricture of the large bowel. 

(c) Dynamic Intestinal Obstruction. — If we obtain a history or 
other evidence of laparotomies or operations on the female genitals, 
of traumatism, reduced herniae, the diagnosis of functional (dynamic) 
obstruction ought not to be very difficult ; but even in these cases 
a positive differentiation is sometimes not easy. For example, in 
obstruction following hernial reduction it is hard to state whether 
the obstruction is of a mechanical (incomplete reduction, adhesions 
of incarcerated intestinal coils) or of a functional nature ; or, when 
a volvulus has been untwisted, it is difficult to state whether the 
intestine has not been twisted anew, or whether the volvulus was 
the only obstructing factor; or whether we are not dealing with 
an obstruction of a dynamic type. As will be seen when we shall 
come to speak of the treatment, these questions are not purely hypo- 
thetical. It is important for the physician to know them before he 
begins treatment. The differential diagnosis can be made only by 
a study of each separate case and by the most careful consideration 



INTESTINAL OBSTRUCTION 449 

of all details. When applied to a complicated case, every tabulated 
scheme utterly fails. 

We have already mentioned that in these cases we must also 
think of hysteria, for the latter condition may cause much diagnos- 
tic difficulty. 

Since it has been thoroughly discussed (p. 368, etc.), we shall 
not enter into the differentiation between mechanical and dynamic 
ileus and acute peritonitis. 

It is evident that the varieties of obstruction which permit of a 
positive diagnosis are not numerous, and even this small group 
presents new phases and abnormalities which may absolutely dis- 
guise the typical clinical ensemble. 

The Treatment of Strictures and Obstructions of the 

Intestine 

Although physicians differ in many points regarding the treat- 
ment of these affections, all agree that we are concerned with one 
of the most difficult and responsible fields of internal pathology. 
This is owing, no doubt, to the uncertainty which attends all cases 
which can be recognised clinically, but more especially those far 
more numerous cases in which the diagnosis is obscure. Even in 
so simple a condition as internal stenosis of the large bowel we can- 
not be certain of the degree of obstruction or the condition of the mus- 
cular layers of the gut above the seat of obstruction. We can note the 
efforts of the hypertrophied intestinal segment to force faecal matter 
through the stricture, but who can say whether it will finally succeed, 
and, if so, when ? What is the anatomical condition of the stricture ? 
How far has it advanced peripherally ? Is rupture impending ? It 
is almost impossible to answer any of these questions. This is also 
true of intestinal occlusions. Let us take the simplest example, 
that of volvulus of the sigmoid flexure. Is the volvulus complete, 
or incomplete ? Is it primary, or caused by a cicatricial stricture 
of benign or malignant character ? What is the condition of the 
twisted bowel ? Is there danger of peritonitis ? Is it beginning, 
or has it already begun % These questions are of the greatest impor- 
tance both as regards the treatment to be instituted and the life of 
the patient ; still it is impossible to clearly and precisely answer 
any of them. If, then, typical cases are so perplexing, how much 
greater the difficulty in cases which do not even admit of localiza- 
tion, let alone of an anatomical diagnosis. 

The difficulty in the selection of a method of treatment is due 



450 DISEASES OF THE INTESTINES 

not so much to the doubtfulness of the gross diagnosis, as to the 
fact that we know so little of the condition of the occluded seg- 
ment during any stage of the disease. Other considerations influ- 
ence our action in individual cases — viz., the age of the patient, his- 
tory of previous exhausting disease, general condition, complicating 
constitutional dyscrasise, etc. Owing to these difficulties, it is im- 
possible to give a schematic account of the treatment of intestinal 
obstruction. The efforts of both surgeons and medical men in dif- 
ferent countries have hitherto been unsatisfactory, because they 
have had no common facts on which to base their plans of treat- 
ment. Only a most comprehensive collective study, such as has 
been so well carried on by Sahli in perityphlitis, may clear up the 
disputed points. At present we must be content to give an account 
of what can be gathered from the rich surgical and medical litera- 
ture of the subject, and from my own experience concerning the 
different methods of treatment. 

I. Treatment of Intestinal Strictures 

Unless we are dealing with a foreign body which may be passed 
per vias naturales, it is impossible to cure an intestinal stricture by 
internal medication. The medical practitioner can only assist in the 
efforts already begun by nature to compensate for the obstruction. 
We possess several means to attain this end : appropriate diet and 
mechanical and medical remedies. 

(a) Diet. — In the General Division we have described the appro- 
priate nourishment in intestinal stenosis. In the section on Intes- 
tinal Carcinoma (page 323) there are special comments which may 
be directly applied to the other forms of chronic stricture of the 
bowel. 

While referring the reader to the above sections, we shall here 
briefly recapitulate the most important facts. The caloric value 
of the diet must be as great as possible. The lower the site of 
the stricture the less will be the difficulty of carrying out these 
principles. The higher the occlusion, the greater will be the 
accumulation of undigested material. The condition is similar to 
that in gastrectasia ; the same difficulties are encountered in 
stenoses of the small bowel situated high up as in dilatation of 
the stomach. 

We must again call attention to the necessity of avoiding 
food indigestible or difficult of digestion, especially if it contain 
much cellulose. 



INTESTINAL OBSTRUCTION 45 1 

In stenosis of the small intestine the food should be fluid or 
semifluid, and should contain appropriate physiological laxatives. 
We need not regard the general warning against so-called flatu- 
lent food, which exists only in the imaginations of thoughtless peo- 
ple ; we should outline the diet according to the individual case. 
The practitioner who distributes printed diet sheets shows that he 
has no conception of the importance of diet in modern therapy. 
In far advanced stenosis of the small intestine nutrient enemata 
may be required. For the details or technic of this procedure the 
reader is referred to other works on this subject.* 

(b) Mechanical Treatment. — This consists in the use of stomach 
lavage and rectal enemata. The former is used only in stenoses of 
the small intestine. Since its technic is quite similar to that em- 
ployed in dilatation of the stomach, we refer the reader to text- 
books on diseases of that organ. Rectal enemata may be employed 
in stenosis of both the large and the small intestines when, as fre- 
quently happens, laxatives must be avoided. They may be of great 
value in stenosis of the small intestine, and in high stenoses of 
the large intestine (occasionally in connection with mild laxatives). 
Thorough irrigation of the rectum is most appropriate, or else small 
enemata of oil or soap, with glycerin, oil, cod liver oil, etc., may be 
given. (Regarding particulars, see Chapter XI.) 

(c) Medical Treatment. — The first question to be considered is 
the treatment by laxatives. They are indispensable in the therapy 
of intestinal stenosis, for, with but few exceptions, the patients suf- 
fer from constipation or from alternating constipation and diarrhoea. 
We have discussed this subject in the General Division (page 189), 
but must again emphasize that drastic purges are always contra- 
indicated. 

Opium and its alkaloids, as well as the belladonna preparations, 
are used in intestinal stenosis either as sedatives or (and this can- 
not be too strongly emphasized) as laxatives. This is especially 
true where there is visible and palpable intestinal spasm. Thus, in 
a case of stenosing cancer of the caecum which I had observed for a 
long time, and in which symptoms of acute occlusion were impend- 
ing, the use of a suppository of opium and belladonna was followed 
by a daily well-formed stool. 

* See Boas, Diagnostik u. Therapie d. Magenkrankheiten, 4te Aufl., 1897, Th. 1, 
S. 293 ; and von Leube, in von Leyden's Handbuch der Ernahrungstherapie, 1897, 
Bd. i, S. 490. 



452 DISEASES OF THE INTESTINES 

Surgical Treatment of Intestinal Strictures 

As already remarked, internal medication cannot have a cura- 
tive effect upon an intestinal stenosis unless the same be due to a 
foreign body. In every case of intestinal stenosis we must there- 
fore consider the advisability of operation. The question of the 
cause of the stenosis will naturally play a very important part as an 
indication. A malignant tumour, no matter where situated, offers 
a worse prognosis than a cicatricial stenosis or a stricture produced 
by a foreign body — for instance, by gallstones. The site of the 
stenosis must also be considered. Owing to the immobility of the 
duodenum, a carcinoma of its superior portion can scarcely be rad- 
ically extirpated, while tumours of the ileum or of the colon offer 
much better chances of complete removal. Benign tumours, though 
of large size, are generally more amenable to radical treatment than 
malignant ones. Extensive adhesions may make the removal of 
the tumour much more difficult, and after its removal may cause 
intestinal obstruction. Autopsy often reveals multiple strictures, 
whereas at the time of operation but one stricture was found and 
removed (Hofmeister and others). It is never possible therefore 
to accurately determine beforehand the nature of the operation re- 
quired, or its result and the prognosis. 

The indications for operation vary with the individual case. 
Generally speaking, benign stenoses, unaccompanied by marked me- 
chanical disturbances, are best treated by internal methods, while 
severe stenoses, in which internal measures have been exhausted, 
are proper subjects for surgical treatment. Mild stenoses of a ma- 
lignant nature (tuberculous and carcinomatous) belong exclusively 
to surgery. In these cases delay may be fatal. On the other hand, 
we have seen that the diagnosis at this stage of the disease is ex- 
tremely difficult. Patients with a beginning stenosis are very rarely 
willing to be operated on. When complete obstruction supervenes 
upon stenosis the treatment is in every respect the same as that 
described under that affection. 

II. Treatment of Intestinal Obstruction 

When the practitioner is confronted with a case of intestinal ob- 
struction he ought to have a clear idea of the limitations in our 
knowledge of this most dangerous form of intestinal disease. It 
would be of incalculable value for therapeusis if by some method 
similar to radiography we could actually see how an intestinal seg- 



INTESTINAL OBSTRUCTION 453 

ment is caught in a mesenteric fenestrum, or how a peritoneal 
strand causes intestinal strangulation, or how an angular kinking of 
the bowel is produced by a cheesy degenerated gland, or how a for- 
eign body has obstructed the intestinal lumen. We could then 
immediately exclude a number of cases in which internal treatment 
is useless. These are the mechanical obstructions, most of which 
can only be removed by mechanical means. 

Since our present knowledge does not enable us to localize or to 
recognise the cause of the obstruction in all cases, it is difficult to 
lay down absolute rules for the physician's guidance. Is internal 
treatment absolutely of no avail from the very beginning of the 
case, or shall we wait ? How long shall we wait ? Or is it a case in 
which we can expect so much from internal treatment that surgical 
treatment is uncalled for ? In most cases it is scarcely possible to 
answer these questions, and therefore our treatment must be some- 
what schematic. We would not have it inferred that all cases of 
obstruction are to be treated alike. On the contrary, we should try 
to individualize as much as possible. 

Internal Treatment of Intestinal Obstructions 

This may be divided into dietetic, mechanical, and medical 
measures. 

(a) Diet. — Most clinicians agree that patients with intestinal 
obstruction should have an " absolute diet " [withdrawal of all 
food] (Goltdammer, Curschmann, Ewald, ^Nothnagel, etc.). I have 
already expressed myself (page 152) as somewhat averse to this 
opinion, and I would again explain my views on this subject.* In 
my opinion the diet in obstruction of the large intestine must be 
quite different from that in obstruction of the small bowel. As 
Curschmann ^ states, feeding per os in the latter disease really im- 
poses an additional burden on the intestine, and hence should be 
limited as much as possible, if not entirely given up. It is different, 
however, in obstruction of the large intestine. In these vomiting 
does not always occur ; when present it is not usually very violent, 
and, what is very important, it very rarely becomes faecal. The 
view often expressed, that there is a suspension of the motor and 
of the resorptive power of the intestinal segment lying proximal to 

* Above all, we must discard the idea that diet is of secondary importance in 
intestinal obstruction. I believe that patients have lost their lives in consequence 
of this misconception, which is directly opposed to modern views. I consider 
everything of caloric value consumed by the patient as so much gain for him. 
30 



454 DISEASES OF THE INTESTINES 

the obstruction, is true of the small intestine, but as regards the 
large intestine is, so far as I can see, only a pure hypothesis, and 
has never been experimentally proved. Accordingly, it is entirely 
proper to have patients with obstruction of the large bowel con- 
sume as much easily digested nourishment as possible. We must 
proceed carefully and cautiously, and be led by the course of the 
affection in each individual patient. 

The nourishment must be regulated even in its smallest detail. 
It should be a fluid or a semifluid diet, which is absorbed without 
difficulty in the upper bowel and leaves no residue. The follow- 
ing are particularly to be recommended : Iced milk, beef tea, cau- 
dle, meat jellies, and the numerous albuminoid preparations found 
in the market. We may also try small quantities of alcohol in the 
form of cognac, Hungarian wine, sherry, etc. It is not a question 
of a great nutritive result, but when we consider that during the 
course of treatment an operation is often indicated, we must never 
even for an instant forget the importance of stimulation of the 
heart, and of giving the patient large quantities of fluid. 

When from the onset, or from attempts already made, we know 
that patients cannot be fed by the mouth, we should always employ 
nutrient rectal enemata. Where for mechanical causes the enemata 
are not retained, we may (as recommended by Curschmann) attempt 
to obviate the threatening systemic loss of water and the cardiac 
collapse by subcutaneous injections of salt and sugar solutions^ 
Many surgeons appreciate the value of the latter procedure, and 
before beginning operations on patients with cardiac weakness are 
in the habit of injecting saline solutions. 

(b) Mechanical Treatment. — Gastric lavage, introduced into the 
therapy of intestinal obstruction by Kussmaul and Cohn, undoubt- 
edly is the most valuable of our mechanical measures. Its effect is 
to lessen the pressure above the occluded segment and thereby to 
remove the great hindrance to compensation of the obstruction. 
We have already described the value, indications, and technic of 
stomach lavage (p. 184), and we would here again point out that 
this procedure is indicated only in cases of obstruction of the small 
bowel. Gastric lavage will scarcely ever be attended by any great 
success in invaginations of the large bowel, in sigmoid volvulus, in 
internal strictures of the large bowel, in dynamic ileus, in obstruc- 
tion by impacted faeces or enteroliths. 

Under certain conditions rectal injections may favourably influ- 
ence the course of the intestinal obstruction, only, however, when 



INTESTINAL OBSTRUCTION .±55 

the latter is deeply situated. Invaginations may be relieved, im- 
pacted foreign bodies loosened, and incomplete volvulus occasion- 
ally reduced, inspissated faecal masses gradually softened, and the 
paralytic large intestine excited to peristalsis. I consider thorough 
rectal irrigations with soap or emulsified oil solutions (see p. 179) 
most appropriate. We must naturally not expect too much from 
these procedures. 

A few observers have recommended massage in intestinal ob- 
struction. Except perhaps in positive obstruction [!] its use is not 
sufficiently clear. Because of the danger of peritonitis, we would 
further recommend the greatest caution in such manipulations. 

Eegarding puncture of the distended intestine by the Pravaz 
syringe, opinions are very much at variance. This procedure has 
lately been recommended particularly by Curschmann M , O. Rosen- 
bach 84 , Fiirbringer 85 , von Ziemssen 86 , and others. On the other 
hand, it has been condemned by almost all surgeons ; for example, 
by Treves,* Korte 87 , Graser,f Kocher 88 , and others. Kocher calls 
it an operation in the dark. 

Curschmann 83 recommends the following technic for puncture of the bowel 
through the abdominal wall : A long needle, having a valve of the calibre of a 
Pravaz aspirator, is thoroughly disinfected. After the valve has been closed 
the needle is passed into the intestinal coil which is most distended, and which 
in each case must be most carefully sought for. The needle is then immedi- 
ately connected with a rubber tube, the latter is passed into a bottle containing 
a watery solution of salicylic acid, and the bottle is turned over a basin con- 
taining the same fluid. When the valve of the canula is opened the intestinal 
gases rise into the bottle, at first in a continuous stream, later more slowly in 
large pearls, finally intermittently. Fiirbringer's advice not to hold the needle 
tightly, but to allow its direction to be guided by the intestine itself, is im- 
portant. The intestines may be punctured at various places. 

This method has for its object the diminution of the tension 
in one or more intestinal coils, thereby allowing the incarcerated 
segment to free itself more readily. Curschmann and Fiirbrin- 
ger claim to have seen cures from the procedure. The method 
requires great caution and should only be used in selected cases. 
It is only indicated in cases with well-defined distended coils, most 
frequently in strangulation and volvulus. It is strongly contraindi- 
cated in intestinal paralysis, in invaginations, in peritoneal irrita- 
tion, especially when a tendency to gangrene exists. 

* Darmobstruction, S. 446 u. f. [Intestinal Obstructions, p. 471 et seq.]. 
f Loc. cit., p. 602. 



456 DISEASES OF THE INTESTINES 

Inflation with air has practically the same significance as ene- 
mata of water. Many cures by this method, particularly in invagi- 
nations, have been published. Impacted foreign bodies may also be 
removed in this manner. Finally, inflation with air may tempora- 
rily or permanently relieve intestinal kinking. In intestinal ulcera- 
tion and peritonitis, however, it is strongly contraindicated. 

Electrical Treatment. — By means of the rectal sounds already 
described (page 178) the faradic or galvanic current may be used for 
the relief of obstruction. Both currents have been employed with 
marked success. Yery favourable results were obtained by Bodet, 
of Paris, who reported 53 cures in 70 cases (!). In France electrical 
treatment is considered of extraordinary value, and is preferred to 
opium. Boudet 89 uses the galvanic current exclusively. After the 
rectum has been filled with one litre of salt solution, the current is 
applied by means of a soft-rubber sound, which in its interior con- 
tains a metallic wire. The instrument is similar to the rectal sound 
described on page 174. The negative pole is connected with the 
sound, and the positive pole is applied to the abdomen or back by 
means of a broad flat plate electrode. The current applied varies 
from 10 to 50 milliamperes, and each application should last from 
20 to 25 minutes. We would naturally hesitate to ascribe to the 
electric current such marked effects in the removal of mechanical 
obstructions, but the high percentage of the reported cures refutes the 
objection that all these were cases of faecal impaction. This method 
deserves more consideration in Germany than it has heretofore 
received. 

(c) Medicinal Treatment. — Practically this is limited to either 
laxatives or sedatives. The relative value of these two classes of 
remedies has been in dispute for more than a century, and only 
within the last ten years has the conclusion been reached that laxa- 
tives are contraindicated in all forms of obstruction except faecal 
impaction and paralytic obstruction. Heidenhain 90 has recently 
pointed out that after hernial reduction and operations for intes- 
tinal obstruction the only proper treatment consists in cleansing 
enemata or laxatives, particularly castor oil. In this we fully agree 
with him. 

In all other cases treatment by laxatives can only do harm. In 
a case of chronic invagination reported from Kussmaul's clinic 91 , a 
dose of castor oil was followed by marked abdominal pain and by 
rigidity of the intussusception, which descended to the anus. After 
morphin, on the contrary, the pains not only decreased, but the 



INTESTINAL OBSTRUCTION 457 

tumour became less marked and the invaginated portion retracted. 
When we consider that during the first stage of occlusion there is 
an attempt to overcome the presenting obstacle by increased peri- 
stalsis, it is evident that an artificial increase of these efforts is en- 
tirely unnecessary and generally harmful. The further filling of 
the distended intestine above the obstruction lessens the chances of 
spontaneous cure. 

With the exception of the two above-named instances, opiates 
pulvus opii, 9i02 to 0:05 grams every three or four hours, or morphin, 
0.01 to 0.03 [!] grams) act effectually. They quiet pain, control vio- 
lent peristalsis, prevent initial shock, diminish vomiting, induce sleep, 
and thus favourably influence the general health. Undoubtedly 
opium, similar to digitalis, is a tonic in heart failure. By quieting 
the intestines, and preventing dragging upon the inflamed perito- 
neum, opium acts as a prophylactic against local peritonitis, which, 
according to present views, may develop in the first stages of ob- 
struction. Opium is best administered in the form of suppositories 
(each containing 0.05 grams), or subcutaneously ([extr. opii] 0.01 to 
0.05 grams). I would recommend the latter method. This treat- 
ment, however, has its indications and its limitations. I repeat that 
opium is to be used only in the first stages of intestinal obstruction, 
and not when general weakness or cardiac paralysis has appeared. 
The latter instances may be those in which, as some surgeons be- 
lieve, the narcotic temporarily masks the serious symptoms of ob- 
struction. This justifies the advice given by some authors, that 
after the therapeutic effect of opium has been obtained one should 
stop its administration for a short time, so that the actual condition 
may not be obscured by any medicine. Opium is also strongly 
indicated when the occlusion is complicated by local or general peri- 
tonitis. Though most of these latter cases die, opium therapy at 
least presents the possibility of limiting the inflammation. 

Thus we possess many remedies and methods for the internal 
treatment of obstruction. So far as I can see. all are agreed upon 
the means to be used, but not upon the manner of their adminis- 
tration. Some advise using all measures at one time, others that 
they be used in rapid succession. I believe everything depends 
upon the diagnosis. For example, gastric lavage is not applicable 
to sigmoid volvulus or invagination ; here one should give air 
insufflations or water enemata. Furthermore, we should advise 
appropriate diet, methodical opium treatment, and always use the 
constant electrical current. In strangulation of the small bowel we 



458 DISEASES OF THE INTESTINES 

should place our main reliance upon opium and gastric lavage. The 
cardiac power may be increased by small rectal enemata, injections 
of saline solution, etc. We should make it our duty to use each 
remedy systematically and persistently, and not discard one method 
before its favourable or unfavourable results have been demon- 
strated. Misdirected overtherapeusis may do more harm than care- 
fully planned expectant treatment. 

Surgical Treatment of Intestinal Obstruction 

~No surgeon, however experienced, can in every case of intes- 
tinal obstruction state positively whether, and at what moment, an 
operation may be necessary. Even if his judgment in one or more 
instances was correct, the very next case might demonstrate that 
this judgment was only accidental. 

A general rule of procedure must be the result of principles 
derived from many observations ; but even then it is almost im- 
possible to formulate satisfactory principles. This is due, above 
all, to the variability of the material upon which the private 
physician, the hospital physician, and the surgeon must base their 
judgment. In the majority of instances the surgeon sees only 
the severest cases of intestinal obstruction and but few of those 
which have been cured medicinally, while the hospital physician, 
and more especially the private physician, frequently succeed in 
curing cases by conservative treatment. In view of the large 
number of cures (33 to 35 per cent, according to fairly well agreed 
statistics), and of the rarity of obstruction from faecal impaction, 
the objection advanced by some surgeons that these are only cases 
of simple impaction does not come into serious consideration. In 
which forms of obstruction do medical cures occur ? They un- 
doubtedly include cases of faecal tumour, gallstone obstruction, in- 
vagination, and, as Curschman B has shown by autopsies, kinking of 
both limbs of a jejunal coil and volvulus of the sigmoid. This 
proves nothing more or less than the possibility of curing even severe 
forms of intestinal obstruction by internal therapeutics (not, how- 
ever, as some surgeons claim, by the opium therapeusis). Thus the 
extreme view of a few surgeons, that every case of mechanical ob- 
struction requires operation, lacks confirmation. 

It is certain, however, that operative procedures have saved 
many lives which would otherwise have been lost. From statis- 
tics of 288 cases, Naunyn w has demonstrated that the earlier the 
operation the better the results obtained. Of those operated dur- 



INTESTINAL OBSTRUCTION 459 

ing the first two days of the disease, 75 per cent, and of those oper- 
ated after the third day, 35 to 40 per cent, were cured. These 
statistics do not refer to all cases of obstruction, but only to those 
which were operated upon. They serve to emphasize the statement 
that if operation is to be performed at all it should be done as early 
as possible. 

Since the results of internal treatment, though not exactly 
favourable, are by no means hopeless, they may be compared with 
those following operation. If we consider only the statistics of 
individual prominent surgeons, we shall find that the results of 
surgical interference are not particularly encouraging. Thus, in 
about 110 cases of intestinal obstruction, Obalinski 36 had a mor- 
tality of 34.5 per cent — just as large a death rate as those cases 
treated internally. Treves,* who reported 122 cases of laparotomy 
up to the year 1888, had about the same mortality, 36.9 per cent. 
Even Kocher 88 , whose results in abdominal surgery are equal to any 
in the world, had as high a mortality as 38 per cent. Hence we may 
conclude that improved antisepsis and technic have not improved 
the unfavourable results of operation. We must therefore search 
for another factor. In his discussion on intestinal obstruction (1889) 
Schede has spoken so convincingly that I cannot but reproduce his 
own remarks : " Every surgeon, particularly every abdominal surgeon, 
must agree with me that these operations [for obstruction], if per- 
formed upon healthy individuals, would only very rarely end fatally 
— in 5 per cent, or at most 10 per cent, of the cases. But there is 
scarcely any other condition which so rapidly lessens and so severely 
taxes the ability of a patient to withstand large operations and long 
abdominal manipulations as intestinal obstruction. A few days are 
often sufficient to bring about a condition in which the much- weak- 
ened patient is unable to bear the simplest operation — for example, 
the search for and division of a pseudo ligament." 

In his recent treatise Kocher has sought for the conditions 
which produce these unfavourable results. He found them in the 
changes which the intestine suffers in consequence of disturbances 
in its circulation. The epithelium of the obstructed segment is 
destroyed, allowing micro-organisms to find their way into the peri- 
toneum, and cause peritonitis. Putrefying substances are more 
easily absorbed from a mucous membrane denuded of its epithe- 
lium, hence an auto -intoxication (or sepsis) results. Kocher has 

* Darmobstruction, S. 461. 



460 DISEASES OF THE INTESTINES 

likewise called attention to the danger of perforation from ulcers 
which develop above the stricture (" distention ulcers "). 

The chances of operative success are also considerably lessened by 
the difficulty, even during operation, in recognising existing condi- 
tions. Any one who has witnessed the efforts and the time required 
to control and replace the distended intestines which continually 
protrude from the abdominal cavity will understand that the 
strength of the patient is often exhausted before the actual opera- 
tion begins. 

In addition, it is often impossible before operation to deter- 
mine the site or the type of obstruction. 

Where shall the incision be made ? Which intestinal segment 
shall be sought for ? Is there one obstruction, or, as occasionally 
happens, are there several, and, in the latter instance, which one 
occludes the bowel ? From this it can be readily understood that 
the surgeon is often confronted with insurmountable difficulties. 

If we are to draw the proper conclusions from this discussion, 
we must concede that the results and dangers of internal and oper- 
ative treatment are about the same. In any given case, therefore, it 
will be the duty of the physician to carefully consider which method 
— operative or internal treatment — offers the better chances for 
recovery. 

The special conditions of the case, the kind of obstruction, the 
age and strength of the patient, and the results obtained by inter- 
nal therapy, are factors to be considered. The sum total of ex- 
periences reported, favourable as well as unfavourable, must also 
influence us in our decision. Regarding this point the following 
statements may be made : 

In the most severe forms of obstruction — strangulation and, 
incarceration — the chances of cure by internal measures are very 
small indeed. If in the very beginning of the disease the symp- 
toms are severe and the clinical signs of internal strangulation are 
present, and if a short trial with opiates and gastric lavage has been 
without result, operative interference is undoubtedly indicated. 

In those cases of obstruction due to an old or recent external 
hernia, the indication for operation is also very clear. Statistics 
show that here the chances of cure are much better than in any 
other form of obstruction. According to Naunyn, 72 per cent of 
the cases are cured. These favourable results have been obtained 
because the diagnosis can frequently be made before operation, and 
the field of operation is limited. 



INTESTINAL OBSTRUCTION 461 

In gallstone obstruction the results are not so satisfactory, and 
we must be more guarded in our prognosis. The chances of spon- 
taneous cure are comparatively good (according to Courvoisier, 56 
per cent, Lobstein, 52 per cent, Naunyn-Schiiler and Dufort, 44 
per cent), while for the operated cases Naunyn (23 cases) reports 
a mortality of TO per cent, and Lobstein (33 cases) a mortality of 
60.1 per cent. 

From this it follows that surgical treatment of gallstone ob- 
struction does not as yet offer such favourable results that operation 
ought be immediately advised. Since the symptoms of this form 
of obstruction generally develop slowly^ we should first carefully 
try the internal therapeutic measures which have been described. 
The time for operation must be decided upon in each individual 
case. 

Regarding operation for other foreign bodies there are not at 
present sufficiently extensive statistics from which to draw conclu- 
sions. It is a well-known fact that even large bodies may pass 
through the intestines without difficulty. Since in the majority 
of these cases operation is followed by favourable results, we should 
not too long employ internal therapeutic measures if intestinal 
obstruction develops. Obstruction from ascarides (a rare form) 
may also demand operation. 

Most authorities agree that as soon as the diagnosis of invagina- 
tion is made the case should be handed over to the surgeon. Sta- 
tistics bear out the complaint of surgeons that patients with invagi- 
nation are generally referred to them too late. Barker 92 , for exam- 
ple, cured 7 out of 11 cases, a result which he declares is due to his 
operating as early as possible. According to Gibson 93 , who in his 
article gave a table of all cases (239) operated on up to the year 
1896, the general mortality is 53 per cent ; in those operated on on 
the first and second days the mortality is only 39 to 41 per cent ; on 
the third day, 62 per cent ; on the fourth and fifth days, 72 per cent ; 
and on the sixth day, 100 per cent. He explains these differences 
by the fact that even as early as the second day 14 per cent of the 
cases are already irreducible ; on the third day, 38 per cent ; on the 
fourth, 57 per cent ; and on the seventh, 80 per cent. Gibson gives 
the proportion of deaths in the reducible and irreducible invagina- 
tions as 38 : 82. The age of the patient naturally plays a great part 
in the indication for operation. Gibson's statistics show a mortality 
of 82 per cent in patients less than three months old ; the mortality 
gradually decreases up to the tenth year, when it is 37 per cent, 



462 DISEASES OF THE INTESTINES 

increasing again to the fifteenth year (68 per cent) ; after this it 
approaches the adult mortality (62 per cent). 

These figures show that, even in cases operated on early, the 
death rate from invagination is considerable. The results of con- 
servative treatment are still more unfavourable. 

Since the above statistics demonstrate that early operations (up 
to the third day) offer the most favourable chances, we should not 
continue too long with palliative treatment. Surgeons state, how- 
ever, that palliative treatment should not be entirely neglected. 

For example, Eydygier 94 , in his latest work, recommends non- 
surgical treatment at first — electricity, gastric lavage, rectal enemata 
and distention with gas in the knee-chest position, massage, and at- 
tempts at reduction of the invagination in deep narcosis. Only 
when one or all of these measures fail is operation to be resorted to. 

Chronic invagination is somewhat more amenable to conserva- 
tive treatment, and the appropriate therapeutic measures may for 
some time be tried. If these are ineffectual and the patient's con- 
dition becomes alarming, it is best to operate at once. According 
to Rydygier's rather small statistics, the mortality from operation 
is only 24 per cent. 

In volvulus, particularly of the sigmoid, the indications for opera- 
tion are different. Naunyn 37 advises delay and individual consider- 
ation of the cases. The results of surgical treatment are by 'no 
means excellent, though in 19 cases of volvulus of the sigmoid (in 
14 of which the correct diagnosis was made) Obalinski cured 10 by 
operation. Nothnagel * does not agree with K"aunyn's conclusions, 
and pleads for active interference not alone in severe but also in 
mild cases. For the following reasons I am inclined to agree with 
Nothnagel. It is not particularly difficult to diagnosticate sigmoid 
volvulus, the surgeon can readily find the obstruction, and, if the 
volvulus was not originally incomplete, the chances of spontaneous 
reduction are very small. By manipulations through the rectum, 
we shall only rarely succeed in producing a permanent cure. On 
the other hand, we must remember that the symptoms of volvulus 
usually develop slowly, that there is usually no fsecal vomiting, and 
that the patient's general condition remains satisfactory for quite 
a time. Accordingly, unless the disease assume an exceptionally 
severe course, we may wait two or three days for a spontaneous 
reduction. If within this time this has not occurred, operative 

* Darmkrankheiten, S. 425. 



INTESTINAL OBSTRUCTION 463 

interference is at once necessary. If, as is very often the case, a 
carcinoma or other tumour is the underlying cause of the volvulus, 
there will be all the more reason for surgical interference, since by 
operation we not only relieve the volvulus, but also may remove 
its cause. A spontaneous reduction will not permanently cure the 
condition, as the volvulus is very apt to recur. 

All authorities agree that the surgical is the only proper treat- 
ment for internal intestinal strictures. Since these generally de- 
velop slowly, the question of operation will have to be decided 
before there is complete intestinal obstruction. Whether we ought 
to delay or immediately take active measures, will depend upon the 
site and type of obstruction, and particularly upon the acuteness of 
the symptoms. Even should spontaneous cure occur, it would only 
be a respite, hence there is no reason for long delay. It is true, 
however, that the results of operations for tubercular and carcinom- 
atous strictures are only temporary, and in cases of multiple stric- 
tures a fatal termination is unavoidable. 

Intestinal obstruction by f cecal impaction is not amenable to 
surgical treatment. Here the internal measures already described 
(purgatives, rectal injections of oil, soap and water irrigations, 
intestinal faradization or galvanization) are in place. Unfortu- 
nately, the diagnosis is often so extremely difficult that an operation 
may be necessary. After the diagnosis has been established, even 
in the severe forms, internal treatment alone is indicated. 

Unless the intestinal paralysis is reflex in character (apparent 
reduction of external hernia, inflamed, undescended testicle, etc.), 
and its cause can be removed by operative or other methods, intes- 
tinal paralyses are to be treated as expectantly as possible. A 
serious result may often be averted by intestinal irrigation, electrici- 
ty and purgatives. If these do not succeed, the best procedure is 
the formation of an artificial anus as high up as possible. 

In the foregoing we have described the indications for opera- 
tive treatment of intestinal obstruction. Discussion of the opera- 
tive technic belongs rather to surgical literature.* We shall briefly 
call attention to a few of the principal points involved. 

In every case of obstruction the aim of surgery is undoubt- 
edly to remove the cause, and to attempt a permanent cure by lap- 
arotomy. Unfortunately there are often exceptions to this ideal 



* An excellent resume by E. Graser may be found in Penzoldt u. Stintzing's 
Handbuch, Bd. iv. 



464: DISEASES OF THE INTESTINES 

result. Either the strength of the patient is insufficient, or the sur- 
roundings render radical operation impracticable, or existing condi- 
tions are so complicated that direct removal of the hindrance is 
too dangerous. In these cases enterostomy is the operation adopted 
by almost all surgeons. 

In the Congress for Internal Medicine, 1889, Schede 95 warmly 
advocated enterostomy. From his experience with two cases, he 
pointed out that the formation of an artificial anus might not only be 
a palliative but a curative operation. On the other hand, von Oet- 
tingen 96 , from more extensive statistics, showed that enterostomy has 
not been successful in any case of volvulus with axial torsion, or in 
severe incarceration and strangulation ; but that it had succeeded 
in intestinal kinking. In acute invaginations also, Rydygier 94 , Gib- 
son 93 , and Ludloff 92 would limit the formation of an artificial anus 
to those patients whose strength does not allow of resection of the 
invagination. If the condition of the patient improves, a radical 
operation is later indicated. 

From the above description it can be seen that there is a distinct 
gap between the therapeutic principles of the physician and of the 
surgeon, which will only be filled when the number of surgical 
cures becomes much greater than the medical. Excepting with a 
few surgeons, this at present is not the case. The changes pro- 
duced in the obstructed intestinal segment and the resulting serious 
general condition develop so rapidly, that, to employ a common 
expression, the surgeon, even though operating at the earliest mo- 
ment, generally operates too late. 

LITERATURE 

1. Leichtenstern. von Ziemssen's Handbuch, Bd. vii, 2, 2te Aufl., S. 416. 

2. Nothnagel. Darmerkrankungen, S. 189. 

3. Wegele. Mtinchener med. Wochenschr., 1898, No. 16. 

4. Leichtenstern. von Ziemssen's Handbuch, Bd. vii, 2, S. 411 u. 418. 

5. Cahn. Berl. klin. Wochenschr., 1886, No. 22. 

6. Riegel. Zeitschr. f. klin. Medicin, 1886, Bd. xi, S. 187, and Deutsche 

med. Wochenschr., 1890, No. 39. 

7. Hochhaus. Berl. klin. Wochenschr., 1891, No. 7. 

8. Schiile. Ibid., 1894, No. 45. 

9. Reiche. Jahrb. d. Hamburger Krankenanstalten, 1892, Bd. ii. 

10. Herz. Deutsche med. Wochenschr., 1896, No. 23 u. 24. 

11. Pic. Revue de medecine, Dec. 1894, et Jan. 1895. 

12. Rewidzoff. Arch. f. Verdauungskrankheiten, 1898, Bd. iv, S. 369. 

13. Boas. Deutsche med. Wochenschr., 1891, No. 28. 



INTESTINAL OBSTRUCTION 435 

14. Wilms. Beitrage z. klin. Chirurgie, Bd. xviii, S. 2, 1897. 

15. Boas. Zeitschr. f. klin. Medicin, Bd. xvii, H. 1 u. 2, 1890. 

16. Kuttner. Beitrage z. klin. Chirurgie. 1899, Bd. xxiii, H. 2, S. 505. (Here 

will be found the literary references indicated in the text.) 

17. E. Frankel. Cited from Munch, med. Wochenschr., 1896, No. 28; Mit- 

theilungen aus d. Hamburger Staatskrankenanstalten, 1897, Bd. i, S. 61. 

18. Hofmeister. Beitrage z. klin. Chirurgie, 1896, Bd. xvii, S. 577. 

19. Litten. Zeitschr. f. klin. Medicin, Bd. ii, 1881, S. 702, etc. 

20. KnudFaber. Berl. klin. Wochenschr., 1897, No. 30. 

21. Johnson and Wallis. Cited by K. Faber (reference 20). 

22. F. Treves. Darmobstruction ; translated by Dr. Arthur Pollak. Leipsic, 

1888, p. 354. [Intestinal Obstruction; its Varieties, etc. New York, 
1899, p. 294.] 

23. Rosenstein. Berl. klin. Wochenschr., 1881. 

24. Jaccoud. Traite de pathologie interne. 

25. Briquet. Traite clinique et therapeutique de l'hysterie. Paris, 1859. 

26. Leichtenstern. Yerhandlungen d. Congresses f. innere Medicin. 1889. 

(Cited from a report.) 

27. Kuttner. Yirchow's Archiv, 1868, Bd. xliii. 

28. Hilton Fagge. Guy's Hosp. Rep., vol. xiv, 1869. (Cited from Naunyn, 

Grenzgebiete d. Chirurgie u. Medicin, vol. i.) 

29. von Wahl. Centralbl. f. Chirurgie, 1889, S. 155; Archiv f. klin. Chirurgie, 

1889, Bd. xxxviii, S. 233. 

30. Kader. Centralbl. f. Chirurgie, 1891, Beilage, S. 110; Inaug.-Diss.. Dor- 

pat, 1891; Arch. f. klin. Chirurgie, 1891, Bd. xlii; Deutsche Zeitschr. f. 
Chirurgie, Bd. xxxiii. 

32. von Zoge-ManteufTel. Yerhandl. des 8. Congresses f. innere Medicin, 1889, 

S. 93. 

33. Schede. Yerhandl. des 8. Congresses f. innere Medicin, 1889, S. 102. 

34. Fenwick. Obscure Diseases of the Abdomen. London, 1889. 

35. Schlange. Archiv f . klin. Chirurgie, 1889. Bd. xxxix, S. 429 ; Volkmann's 

Sammlung klin. Yortrage, 1894, N. F. No. 101. 

36. Obalinski. Arch. f. klin. Chirurgie, 1896, Bd. xlviii. H. 1. 

37. Naunyn. Mittheil. aus d. Grenzgebieten, 1895, Bd. i, S. 98. 

38. Tietze. Deutsche Zeitschr. f. Chirurgie. 1897, Bd. xlv, H. 1 u. 2, S. 17. 

39. Englisch. Oesterr. medicin. Jahrbucher, 1884, No. 2 u. 3. 

40. Frank. Berl. klin. Wochenschr., 1887, No. 38. 

41. von Engel. Prager medicin. Wochenschr., 1899, No. 14. 

42. Israel. Berl. klin. Wochenschr., 1892, No. 1. 

43. Curschmann. Yerhandl. des 8. Congresses f. innere Medicin, 1889. 

44. Leichtenstern. Berl. klin. Wochenschr., 1874, No. 40. 

45. P. Guttmann. Deutsche medicin. Wochenschr., 1884. No. 14; Berl. klin. 

Wochenschr., 1893, No. 2. 

46. Karl Abel. Berl. klin. Wochenschr., 1894, No. 4 u. 5. 

47. Melchioris. Cited from Treves, Darmobstruction, p. 142. 

48. Curschmann. Deutsches Arch. f. klin. Medicin, Bd. liii, H. 1 u. 2, S. 1. 

49. Bottcher. Yirchow's Archiv, 1886, Bd. civ. 

50. Fleiner. Ibid., 1885, Bd. ci. 



466 DISEASES OF THE INTESTINES 

51. Raffinesque. Etude sur les invaginations intestinales chroniques. These 

de Paris, 1878. 

52. D'Arcy Power. Some Points in the Anatomy, Pathology, and Surgery of 

Intussusception. London, 1898. 

53. Leichtenstern. Prager Vierteljahrsschrift, Bd. cxviii. 

54. Henoch. Kinderkrankheiten. Berlin, 1881, S. 453. 

55. Kelling. Arch. f. Verdauungskrankheiten, 1895, Bd. i, H. 2, S. 172. 

56. Westphalen. Ibid., 1898, Bd. iv, H. 1, S. 63. 

57. Riedel. Mittheil. aus d. Grenzgeb. d. Medicin u. Chirurgie, Bd. ii, S. 528. 

58. Schnitzler. Wiener klin. Rundschau, 1895, No. 37. 

59. L. Meyer. Virchow's Archiv, Bd. xcv. 

60. Mikulicz. Arch. f. klin. Chirurgie, 1895, Bd. Ii. 

61. Korte. Arch. f. klin. Chirurgie, 1893, Bd. xlvi, S. 331. 

62. E. Lobstein. Beitrage zur klin. Chirurgie, 1895, Bd. xiv, S. 394. 

63. Kirmisson-Rochard. Archives generates. Mars, 1892. 

64. Sick. Deutsche medicin. Wochenschr., 1891, S. 268. 

65. Kostlein. Wiirtemb. Correspondenzbl. , 1876, No. 6. 

66. Dessauer. Virchow's Archiv, Bd. lxvi, S. 271. 

67. Maclagan. Lancet, vol. i, p. 123, 1888. 

68. Courvoisier. Casuistisch stat. Beitrage zur Pathol, u. Chirurgie d. Gallen- 

wege. Leipzig, 1890. 

69. Down. Quoted from Treves's Darmobstruction, S. 336 [and Intestinal 

Obstructions, p. 197]. 

70. Davaine. Traite de Entozoaires et de maladies vermineuses. 2 me . edit., 

Paris, 1871. 

71. Heller. Darmschmarotzer. Ibid., S. 586. 

72. Mosler u. Peiper. Thierische Parasiten. Nothnagel's Handbuch, Bd. vi, 

1894, S. 197. 

73. Heidenreich. Semaine medicale, 1891, No. 42. 

74. Simon. Revue medic, de l'Eto, 1892, No. 8. (Cited from Mosler and 

Peiper.) 

75. Frikker. Deutsche medicin. Wochenschr., 1897, No. 4. 

76. von Leube. Naturforscherversammlung in Dtisseldorf (from report in the 

Munch, med. Wochenschr., 1898, No. 41). 

77. Strauss. Berl. klin. Wochenschr., 1898, No. 38. 

78. Sand6z. Correspondenzbl. f. Schweizer Aertze, 1887, S. 41. 

79. Strehl. Deutsche Zeitschr. f. Chirurgie, 1899, Bd. lvi, H. 5 u. 6. 

80. Grundzach. Wiener medicin. Presse, 1895, No. 10. 

81. Hochenegg. Wiener klin. Wochenschr., 1897, No. 51. 

82. Graser. Penzoldt-Stintzing's Handbuch d. speciellen Therapie, lte Aufl. r 

Bd. iv, S. 568. 

83. Curschmann. Reference 43 ; also Deutsche medicin. Wochenschr., 1887^ 

No. 21. 

84. O. Rosenbach. Ibid. 

85. Fiirbringer. Verhandl. des 8. Congresses f. innere Medicin, 1889. 

86. von Ziemssen. Ibid. 

87. Korte. Berliner Klinik, 1891, No. 36. 

88. Kocher. Mittheil. aus d. Grenzgebieten, 1898, Bd. iv, S. 2. 



INTESTINAL OBSTRUCTION 467 

89. Boudet (de Paris). Progres medical, 7 et 14 Fevrier, 1885. 

90. Heidenhain. Deutsche Zeitschr. f. Chirurgie, 1897, Bd. xliii, S. 201. 

91. Asch. Inaug.-Diss., Strassburg, 1880. (Cited from Graser in Penzoldt- 

Stintzing's Handbuch, 1. Aufl., Bd. iv, S. 596.) 

92. Barker. Quoted from Ludloff, Grenzgebiete, 1898, Bd. iii, H. 5, S. 603. 

93. Gibson. New York Med. Record, July 17, 1894. 

94. Rydygier. Deutsche Zeitschr. f. Chirurgie, 1896, Bd. xlii. 

95. Schede. Archiv f. klin. Chirurgie, Bd. xxxvi, H. 3. 

96. von Oettingen. Inaug.-Diss., Dorpat, 1888. 



CHAPTEE XXII 

TYPHLITIS, PERITYPHLITIS {APPENDICITIS) 

Preliminary JRemarks. — Typhlitis is an inflammation of the 
caecum and the surrounding peritoneum. Perityphlitis or appen- 
dicitis* is an acute or chronic inflammatory process, which origi- 
nates in the vermiform appendix, and may remain strictly local- 
ized or spread to the surrounding parts. 

At the present day we believe that in these inflammatory affec- 
tions the cascum is much less involved than the appendix. Thus 
the long-forgotten teachings of Louyer, Viller, Nay (1824), Melier 
(1827), Grisolle, and others,f which were so obstinately and success- 
fully opposed, are now vindicated. From Talamon we gather that 
Melier had evidently foreseen the possibility of removing a diseased 
appendix. He plainly stated: "If it were possible to diagnose 
these affections with certainty we might conceive of the possibility 
of curing them by means of operation. Perhaps some day this 
result may be achieved." 

Only very recently have the old mistaken views concerning 
appendicitis been overthrown. To a very great extent this advance 
is due to modern surgery. As in many branches of gastro-intestinal 
diseases, here also the autopsy in vivo and post-mortem have borne 
rich fruit (Ribbert, Zuckerkandl, Matterstock, H. Einhorn, and 
others). Internal medicine slowly yielded to modern views, and 
has since added considerably toward extending this new field. The 

* We will employ the terms perityphlitis and appendicitis, though the latter is 
etymologically not exactly correct. Because of its peculiar pronunciation, skoli- 
koiditis (from o-kwAtjI, worm), the name introduced by Nothnagel, will prob- 
ably not come into general favour. The term epityphlitis, recently suggested by 
Kiister, though sounding better than skolikoiditis, is also objectionable, since the 
appendix is not always upon, but may be behind, below, above, or to the side of 
the caecum. 

f Compare the interesting historical development of this question by Talamon, 
Appendicite et Perityphlite, Paris, 1892 ; and by Grobe, Pathologie und Therapie 
der Perityphlitiden, Greifswald, 1896. 
468 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 469 

excellent article of Sahli 1 and the impressive discussion pertaining 
thereto have accomplished much toward this end. 

Surgery soon dominated this new field. In the middle of the 
eighties, with the progress and development of aseptic methods, 
the operative treatment of appendicitis made rapid advance in 
England and America, and soon obtained brilliant results. 

Gradually our ideas of this affection became moderated, and the 
early radicalism was somewhat modified. Indications for internal 
and for operative treatment began to be compared, the results of in- 
ternal and surgical treatment given their proper value, and the occa- 
sional bad effects of the operation (fistulae, abdominal sinuses, her- 
niee, adhesions, etc.) were considered. Both scientifically and prac- 
tically appendicitis was made the boundary between medicine and 
surgery. Before proceeding to a consideration of the diagnosis 
and treatment of this affection we shall, in what follows, state as 
briefly as possible its present status, in so far as it concerns the clin- 
ical view of the disease. 

Typhlitis. — Does it really exist? Has stercoral typhlitis the 
significance attributed to it since Alber's time ? Yiews differ ; a 
few authors (among the modern writers I cite only Talamon*) 
go so far as to deny the occurrence of typhlitis. We may discuss 
these conditions in various ways — e. g., by referring to pathological 
anatomy, to clinical observations, or to the results of the many 
surgical operations. 

Pathological anatomy has long dealt with inflammatory processes 
of the csecum. Ulcerative conditions, particularly, have been 
known since autopsies have been systematically performed. Usually, 
however, these ulcerative conditions were quite different from those 
now in question. They were either typhoid, dysenteric, tubercular, 
stercoraceous, or actinomycotic. As already pointed out in the 
more extensive discussion of these ulcerations, they are by no means 
limited to the csecum, but occur as often in the rectum, the flexures 
of the colon, and the sigmoid flexure. Indeed, it is surprising that, 
excepting the rare cases of pericolitis and sigmoiditis, inflammatory 
processes similar to typhlitis are not found more often in other 
segments of the large intestine. Etiologically, besides ulcerations, 
we must also consider foreign bodies (needles, etc.) and neoplasms 
(particularly cancerous and tubercular). 

What is the status of clinical teaching regarding typhlitis ? The 

* Loc. cit. 
ol 



470 DISEASES OF THE INTESTINES 

symptoms of typhlitis are described as follows : Obstinate constipa- 
tion, tympanites, pain and sensitiveness in the right iliac fossa, 
development of a sausage-shaped faecal tumonr corresponding to the 
position of the caecum (boudin stercoral), moderate fever, and 
increased indicanuria. A perforation of the caecum may occur, and 
death from peritonitis follow. 

It must be admitted that in itself this picture is characteristic, 
but modern research has shown that it cannot be distinguished 
from disease processes which originate in the appendix. There 
is not one symptom which might not also be present in an ap- 
pendiceal inflammation. We cannot present an absolutely indi- 
vidualizing picture of typhlitis, and at the present time it is impos- 
sible to symptomatologically separate appendicitis and typhlitis. 
The results of operations, however, or, as JSTothnagel once appropri- 
ately called it, the results of " biopsy," can only determine the diag- 
nosis during life. 

Increased observations have demonstrated that, though rarely, 
isolated inflammatory processes may affect the caecum or its vicinity 
without involving the appendix. Such observations have been 
reported by Harley 2 , Mariage 3 , Curschmann 4 , Lennander 5 , Porter 6 , 
Kronlein 7 , Menley 8 , Meusser 9 , and others. I agree with Borchardt 10 
that some of these observations will not stand critical investigation, 
but among these there are several (I will only mention the case of 
Lennander, where no appendix at all was to be found) which need 
no forced interpretation, and which prove the occurrence of 
typhlitis.* 

The etiology of typhlitis shows certain variations. There may 
be faecal impaction with suppuration, or there may be adhesions ; 
sometimes there are ulcerations of the most varied kinds, with 
more or less evident perforations. These variations prove that 
typhlitis by no means gives the simple clinical picture that 
appearances would warrant. It is necessary to give up the idea 
of a purely stercoraceous typhlitis, for impacted faeces per se 
rarely produce typhlitis; foreign bodies, ulcerations, adhesions, 
and fixation of the caecum may also cause inflammation of the 
caecum. 

* Grohe (loc. cit.) also reports an observation which belongs here. In a paralytic 
who died of broncho-pneumonia, the caecum was filled with faecal masses. In the 
portion of the intestinal wall opposite the mesenteric attachment there was found 
a slight ulceration of the mucous membrane of the size of a half dollar, which 
could only be explained by faecal impaction. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 471 

Perityphlitis (Appendicitis). — It is now an absolutely estab- 
lished fact that the inflammatory processes which start in the ap- 
pendix greatly preponderate, and that the great majority of dis- 
eases until recently designated as typhlitis, perityphlitis, and para- 
typhlitis likeivise originate in the vermiform appendix. This fact 
is supported not only by anatomical observations (Matterstock, Fen- 
wick, H. Einhorn), but also by the great number of observations of 
the foremost surgeons (Roux, Sonnenburg, Kummell, Lennander, 
Korte, Schede, Eotter, McMurtry, Reginald Fitz, McBurney, 
Fowler, Treves, Beck, Kelynack, Dunn, and others). The abso- 
lute agreement of these surgeons relieves us of the necessity of 
presenting isolated statistics. The question arises as to which are 
the most frequent causative factors. 

To answer this, a brief anatomical description of the relation 
and position of the appendix is necessary. 

The length of the appendix varies from 2-§- to 24 centimetres, the average 
being about 9 centimetres. Its thickness is about that of a goose quill. In 
the newly born the proportion of the length of the appendix to the large intes- 
tine is as 1 to 10; in the adult, 1 to 20. Like the caecum, the appendix has 
a mesentery (mesenteriolum, mesovermium) in which the nourishing blood and 
lymph vessels course. The caecal artery, the lowest offshoot of the superior 
mesenteric, gives off a branch to the mesovermium — the appendicular artery; 
the latter runs along the mesentery parallel to and a few millimetres away from 
the appendix, giving off branches to that organ. The appendicular artery is a 
terminal artery (in Cohnheim's sense), and this accounts for the severe changes 
which may develop in the course of apparently mild cases of appendicitis. The 
mucous membrane of the appendix contains cylindrical cells, Lieberkuhn's 
glands, blood and lymph vessels, and is distinguished from the other intestinal 
segments by its striking abundance of lymph follicles. According to Ribbert u , 
the latter vary very much with the age. In childhood the lymph follicles are 
very large and lie closely together; after the twentieth year they decrease in 
size and become more separated. 

At the insertion of the appendix the so-called valve of Gerlach, or, accord- 
ing to Groh6, more properly the valve of Merling, is sometimes present, though 
frequently absent (Clado, Lafforgue). This structure, however, cannot prevent 
faeces from passing into the appendix. 

Being a functionally unnecessary organ, the appendix presents involution 
changes with increasing age (Ribbert). After disappearance of the epithelium 
there develops a slow proliferation of the connective tissue of the mucosa, while 
the submucosa and muscularis retain their structure. By this process the lumen 
of the appendix becomes gradually narrowed, and in one third of all cases 
absolutely obliterated. 

The relation of the peritoneum is important to an understanding pf the 
anatomical changes. As modern observation (Bardeleben, Luschka, Turner) 
has shown, the entire circumference of the caecum is covered by peritoneum, so 



472 DISEASES OF THE INTESTINES 

that in more than 96 per cent of all cases the appendix lies intraperitoneal^ 
(Maurin 12 , Bryant 13 , F. Von Sydow"). The appendix may accompany the 
caecum in its various changes in position. We will discuss this point more 
fully in the diagnostic section. 

The manner of attachment of the appendix to the caecum is of great surgical 
interest, and, as Krausshold 16 has long since shown, may vary considerably. 
The most frequent insertions of the appendix are internally to, behind, below 
and in front of the caecum, and finally in the small pelvis (Bryant). 

The causes of appendicitis are direct and predisposing. 

Of the direct causes faecal concretions play an important part. 
According to Ribbert u they occur in 10 per cent of appendicitis ; 
according to Renvers 16 , Treves n , and Murphy 18 in about one third 
of all cases ; according to some authors (Matterstock) they produce 
50 per cent of the cases. 

Other foreign bodies are found, but they are more rare than 
coproliths, being present in about 2 per cent of all cases. 

The presence of faecal concretions (which, by the by, have only 
a central nucleus of faeces, the remainder consisting of several layers 
of mucus (Ribbert u ) ), by no means explains the entire etiology of 
appendicitis, for there are many cases in which these concretions 
are not present, but in which the appendix contains mucus or fluid 
faecal masses. In view of this, we must ask whether faecal con- 
cretions really play a considerable part in the etiology, or only 
favour the development of an inflammation. This question has 
been variously answered. In my opinion the concretion acts only 
as a predisposing factor in conjunction with other conditions soon 
to be considered. 

We have already described the peculiar structure of the appen- 
dix, its abundance of lymph follicles, the absence of smooth muscle 
fibres, its extraordinary length in proportion to its narrow lumen, 
its tendency to changes of position and form, and, finally, the ab- 
sence of anastomoses in the appendicular artery. All these circum- 
stances favor catarrhal inflammation, which, no matter what its 
cause, leads to increase and stagnation of secretion. 

The chief cause of appendicitis without doubt lies in the stagna- 
tion of its secretion. The pathology of other organs demonstrates 
the harmful effect of stagnating secretions in hollow viscera. In 
the gastro-intestinal canal they are the main cause of severe nutri- 
tive disturbances; in the gall bladder they are to a great extent 
responsible for formation of stones ; and in the course of a surgical 
wound the absence of sufficient flow of secretion constitutes one of 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 473 

the most important complications. Evidently all this also applies 
to the appendix. As long as there is free and regular communica- 
tion between the mucous membrane of the appendix and caecum, 
even though virulent bacteria be present, no disturbance will fol- 
low. The moment, however, the communication ceases, and the 
outflow of secretion is prevented either by faecal concretions, ca- 
tarrhal swelling, partial obliteration, or by compression or adhesion 
of neighbouring organs, decomposition of the contents, inflamma- 
tion, ulceration, gangrene, and suppuration occur. 

As demonstrated by the careful studies of Tavel and Lanz 19 , 
Eckehorn 20 , Morris 21 , and others, bacteria, especially the bacterium 
coli communis, undoubtedly play a prominent part in the above 
processes. The destructive powers of the bacteria are only exer- 
cised when a favourable medium for considerable development, and 
perhaps also for their transplantation, is offered. 

As already mentioned, this medium is furnished by the stagna- 
tion of secretion, by loss of epithelium, by erosions, or by catarrhal 
or pressure ulcerations, which, owing to the poor blood supply of the 
appendix, develop only too easily. 

If, therefore, the faecal concretions are given their proper, rather 
large predisposing part in the etiology of perityphlitis, and if we do 
not underestimate the influence of the bacteria natural to the appen- 
dix, the direct development of the inflammatory process must be 
sought for in the peculiar anatomical form and structure of the 
appendix, which produce and make possible the deleterious action 
of both the above factors. 

Another circumstance which speaks in favour of the above view 
is the infrequency of perityphlitis in childhood. In the statistics of 
Matterstock, of 474 cases of perityphlitis, there are only 46 cases 
between the ages of one and ten years. Out of 228 cases Fitz 
gives 22 of the latter age, and out of 130 Sonnenburg only 26. 
Still more convincing are the statistics of the pediatrists. From 
the excellent monograph of Karewski 22 on perityphlitis in child- 
hood, we tind that Henoch, during the years 1890-1894, among 
3,486 sick children, saw only 2 cases of appendicitis. Baginsky, in 
1890-1891, of 494 cases, saw none ; of 415 cases in 1891-1892 he 
also observed none ; of 1,692 cases in 1892-1893, he observed but 
3; in 1893-1894, of 2,234 cases, only 4; in 1895, of 2,580, 8 peri- 
typhlitis cases ; altogether 15 cases out of a total of 7,413 diseased 
children. 

Again, from H. Einhorn's statistics from the Pathological Insti- 



474 DISEASES OF THE INTESTINES 

tute of Munich, the number of cases of perityphlitis in proportion 
to total autopsies was 5 per 1,000, the cases in children being 2 per 
1,000. Since the diagnosis of this affection in children is quite 
difficult, this proportion is rather too large than too small. In this 
connection Kothnagel's 23 statistics are also of great value. Of 
44,910 autopsies performed in the Vienna General Hospital in the 
years 1870 to 1896, there were 148 cases of peri- and paratyphlitis 
(0.3 per cent). Of these 148 cases only 2 were in children between 
one and nine years of age. 

The explanation of these facts is furnished by the investigations 
of Stein er 24 , Ribbert 11 , and Zuckerkandl 25 . These observers found 
partial or total obliteration of the appendix with increasing age, 
while obliteration was extremely rare in children, particularly before 
the fifth year. In my opinion the large size of the lumen of the 
appendix, whereby accumulations of secretions and pressure necrosis 
are prevented, is of great importance in explaining the rarity of 
appendicitis in children. 

Besides these essential factors certain predisposing circum- 
stances play an undoubted part. Talamon * lays stress on hered- 
ity. Some families present a predisposition to appendicitis. Sahli 
also mentions such cases. Traumatism is mentioned as a factor 
by some authors (Coley ^, Small * Korte-Borchardt 10 , and others). 
Various observers give chronic constipation as a predisposing 
cause. In 209 appendicitis cases Fitz 1T found constipation only 
38 times. 

I believe we must differentiate between acute and chronic 
recurring appendicitis. According to my experience chronic con- 
stipation is quite often a factor in the latter, but much less so in 
the acute form. Treves 17 regards bad teeth and insufficient chew- 
ing of food as frequent causes of appendicitis. Dyspeptic con- 
ditions are said to favour this disease. In English literature par- 
ticularly, rheumatism and gout are mentioned as predisposing to 
an attack. 

Recently G-olubeff • has directed attention to the frequent si- 
multaneous occurrence of perityphlitis in Moscow, and has therefore 
attributed to it an epidemic character. From a study of cases 
occurring in Erlangen during a period of nine years, Penzoldt 30 
could not substantiate this conclusion. At times I have seen nu- 
merous simultaneous perityphlitis cases in Berlin ; a number of 
factors may here have acted together. 

We might further increase the list of accidental causes of ap- 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 475 

pendicitis, and add that affections of the female genitals also pre- 
dispose to appendicitis. All these facts can not overthrow the real 
practical etiological considerations that we have above attempted to 
establish. 

Perityphlitis of tuberculous or actinomycotic origin presents a 
certain individuality. The former not infrequently occurs as a 
latent symptom of general and particularly of intestinal tuberculo- 
sis. On the other hand, primary tuberculous disease of the appendix 
with a characteristic picture of appendicitis is exceptional. From 
a very large material Sonnenburg reports but 3 cases of this 
kind. Borchardt 10 also reports 3 cases occurring in Korte's hos- 
pital service. Karewski 22 has operated on 4 cases in children, in 
2 of which he thinks the disease was a primary isolated tubercular 
appendicitis. According to Borchardt, tuberculosis may produce 
perityphlitic abscesses which rupture externally and cause csecal 
fistulee. 

Actinomycotic appendicitis is more infrequent. In his mono- 
graph Sonnenburg could collect only 12 cases of this kind. Karew- 
ski ^ reports a further case. 

In conclusion, we wish to discuss the relative frequency of this 
disease in the various periods of life and its relation to sex. 

We have already dwelt upon the relative infrequency of 
appendicitis in childhood. Numerous statistics (Matterstock, Fitz, 
Nothnagel, Sonnenburg) demonstrate that the second and third 
decades of life present a very striking predisposition to appendi- 
citis. According to the extensive tables of Matterstock, 63 per 
cent of all cases of appendicitis occur during these periods. Ex- 
cept those of H. Einhorn, the remaining statistics indicate a simi- 
lar conclusion. 

Regarding the relative frequency in the two sexes, according 
to the tabulations of Yolz, Bamberger, Matterstock, Sonnenburg, 
Rotter, Nothnagel, Fitz, Pravaz, and Fenwick, appendicitis is 
much more frequent in men than in women, while others (Ein- 
horn, Lennander, and Kiimmell) could discover no material differ- 
ences in frequency. Nothnagel correctly points to the greater 
frequency of appendicitis in the male even in childhood. This 
is also evidenced by Matterstock's extensive tables (51 male chil- 
dren to 21 female). 



476 DISEASES OF THE INTESTINES 

Symptomatology and Diagnosis 

A. Acute and Chronic Typhlitis 

"We have already briefly described (page 432) the symptoms of 
acute typhlitis, and have mentioned pain and sensitiveness to pres- 
sure in the caecal region, tympanites, palpable faecal accumulation, 
and fever. This description presupposes a simple stercoraceous 
typhlitis. We have as yet no clear clinical picture of the remain- 
ing forms of typhlitis, at least not of the acute forms. This is evi- 
dent from the fact that in almost all operations in which typhlitis 
was found the diagnosis of appendicitis had been made. It is 
therefore idle to lay down diagnostic rules and principles for these 
other forms of typhlitis. But in the present state of our knowl- 
edge even the differentiation between stercoraceous typhlitis and 
appendicitis must be made with the greatest reserve. Under the 
following circumstances the diagnosis of stercoraceous typhlitis 
might be ventured. Sudden, obstinate constipation, moderate 
sensitiveness over the caecum, mild fever or none at all, and 
absence of severe general symptoms. The intensity of the sponta- 
neous pains appears to me irrelevant. Objectively, we should be 
able to palpate a faecal tumour characterized by its compressibility 
and perhaps extending high up along the ascending colon. There is 
a dull percussion note over the tumour. Clinical course : Immediate 
disappearance of the tumour and of all symptoms after a laxative or 
enema. Only in the presence of a clinical ensemble as well marked 
as this can the diagnosis of [stercoraceous] typhlitis be made with a 
fair degree of probability. So typical a picture is certainly not 
frequently seen in practice, because the majority of patients have 
already taken laxatives before medical advice is sought. Even in 
such typical instances it is impossible to positively differentiate the 
affection in question from appendicitis or appendicular colic. We 
shall recur to this point in the section on differential diagnosis. 

Under appropriate circumstances chronic typhlitis can be more 
easily diagnosticated than the acute form. The absence of violent 
initial symptoms, the very slow onset, the palpability of a resist- 
ance in the caecal region, all point toward the diagnosis. Since 
chronic typhlitis is usually tuberculous, dysenteric, or carcinomatous 
in character, the previous history or other clinical phenomena may 
give important diagnostic data. The presence of stenotic symptoms 
will often serve to make the etiology positive. As proved also by 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 477 

surgical experience, it is very difficult to diagnosticate adhesions about 
the caecum [perityphlitis sensu strictiori). Even admitting the very 
rare instances in which the adhesions can plainly be felt, it will be 
scarcely possible to proye their origin from the caecum. At most 
this can only be surmised. 

B, Perityphlitis (Appendicitis) 

1. Acute Perityphlitis 

In many instances the diagnosis of acute perityphlitis is as easy 
as that of croupous pneumonia or of an acute monarthritis. Con- 
versely, however, the clinical picture may be so complicated and 
atypical that, despite great experience and ability, error is un- 
avoidable. The statistics of Xothnagel, already given (page 436), 
derived from the very extensive material of the Vienna General 
Hospital, contain a number of such diagnostic errors. These cases 
are the more instructive because they have been under most care- 
ful clinical observation. 

The diagnostic difficulty lies in another direction. Operations 
have taught us the numerous and various changes which the appen- 
dix may undergo : the diseased process may be limited to the mu- 
cous membrane, or to the peritoneal coat, or may affect both ; rup- 
ture may take place into a preformed encapsulated space, into the 
general peritoneal cavity, praeperitoneally, retroperitoneal^, into the 
intestines or other hollow viscera. Even during laparotomy it may 
be impossible to distinguish these various forms of appendicitis. 
It is absolutely necessary, however, to understand the principal 
types, and to be able to recognise the most important clinical com- 
plications of the disease. 

The variations in the clinical picture of appendicitis have led to its 
classification. Sonnenburg a was the first to establish and methodic- 
ally carrv out such clinical divisions. His classification is as follows : 

1. Simple, catarrhal appendicitis, with its acute, chronic, ob- 
structive, and cystic forms. 

2. Perforative appendicitis : (a) with periappendicitis, (b) with 
general peritonitis. 

3. Gangrenous appendicitis : (a) septic peritonitis without per- 
foration, (h) circumscribed or diffuse peritonitis accompanying 
beginning perforation. 

Rotter K has divided perityphlitis more simply into the circum- 
scribed and the diffuse forms. Kummell s divides the cases into the 



478 DISEASES OF THE INTESTINES 

mild, moderate, and severe — an arrangement which is followed by 
Korte. 

Naturally all these classifications are schematic, and give only an 
incomplete idea of the various phases and clinical courses of appendi- 
citis. Rotter's arrangement seems to me the simplest and least pre- 
judicial, but it also incompletely represents the varieties of the 
disease. With much hesitation, we shall follow Sonnenburg's 
nomenclature, discarding only those subdivisions which either go 
too far or not far enough. 

Though such differentiation cannot be made with certainty, we 
shall also distinguish between simple perityphlitis and appendicular 
colic. 

(a) Simple Perityphlitis 

The most prominent symptoms are sudden onset ; acute pain in 
the ileo-caecal region ; sensitiveness to pressure in the region of the 
appendix, and eventually of the tumour ; gastric disturbances ; the 
condition of the pulse and the temperature. 

Each of these symptoms requires detailed consideration. 

1. Sudden Onset. — The patients are usually attacked in the 
midst of general good health. Occasionally, constipation or diar- 
rhoea precedes the attack. The attack very soon becomes so 
marked that the patients are forced to take to bed. 

2. Pain. — This is the most characteristic symptom, and rap- 
idly reaches its greatest intensity. Adults can usually localize 
the pain quite well, but children complain of general stomach 
ache. Some patients locate the greatest area of pain in the centre 
of the abdomen, in the umbilical or epigastric region.* The pain 
is continuous, and shows slight or no remissions. It may radiate 
to the right thigh, the back, the testicle, or the bladder. In the last 
instance bladder symptoms may be present, and there may even be 
retention of urine. The respiration is a useful gauge for the intensity 
of the pain. In well-marked cases the breathing is rapid, superfi- 
cial, and costal ; the patients anxiously avoid deep inspiration. The 
patient feels most comfortable when lying quietly on his back ; every 
movement increases his pain, absolute rest decreases it. 

3. Sensitiveness. — Sensitiveness to pressure over McBurney's 
point is the most valuable and reliable of the objective symptoms. 
The sensitiveness varies in intensity, but in the beginning is fairly 



* [Hartley 77 states that only in one fourth of the cases is the initial pain referred 
to the right iliac fossa. — Tr.] 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 479 

well localized. As Fowler 54 points out, there is a certain amount 
of rigidity on palpation of the right rectus muscle. He also calls 
attention to an interference with the function of the abdominal 
respiratory muscles, evidently caused by the above-mentioned 
superficial and rapid breathing. Regarding the possibility of 
palpating the inflamed appendix, to which Edebohls 35 in partic- 
ular refers, views differ. Sonnenburg, whose opinion is certainly of 
great value, says " that the thickened appendix cannot be palpated 
during acute attacks, but may be palpable in the intervals." 
Fowler 34 speaks of " exceptional identification in cases of chronic 
appendicitis." 

Admitting the possibility of feeling the appendix, this fact is 
on the whole of small practical significance. A circumscribed pain- 
ful area in the ileo-csecal region is a sufficient clinical symptom. 

4. Perityjyhlitic Tumour. — Under appropriate treatment the 
sensitiveness may disappear in a short time, or may increase with 
the onset of high fever and the development of a perityphlitic 
tumour. Of what does this tumour consist ? According to Sahli *, 
it is mainly composed of a thickening of the intestinal wall, the vis- 
ceral and parietal layers of the peritoneum, and the fascia trans- 
versalis of the abdominal muscles ; in addition, there are fibrous 
adhesions of the intestines, not infrequently thickening of the 
omentum, and stagnation of the intestinal contents. 

In general, even small tumours of the iliac fossa are readily 
palpable. In perityphlitis, because of the rapid onset of intestinal 
paralysis, the intestines become distended with gases and the tumour 
is thereby brought nearer to the surface. The tumour is felt either 
as a circumscribed, easily defined mass, or as a diffuse, doughy 
swelling (Roux). In other cases, especially when there is marked 
meteorism, or when the appendix is situated behind the caecum, 
recognition of the tumour by palpation is difficult. In all these 
cases rectal or vaginal examination is of great value, especially 
since the appendix is sometimes situated low down in the small 
pelvis and may there give rise to abscesses. 

In doubtful cases exploratory puncture may render important 
diagnostic aid. At present the views regarding the value of this 
procedure are contradictory. Some prominent surgeons (Sonnen- 
burg, Eoux, Karewski, Fowler, and Treves) have entirely given up 
puncture, while Korte, Borchardt, Lauenstein, as well as the major- 
ity of internal practitioners (v. Leyden, A. Fraenkel, Furbringer, 
Renvers, Curschmann, Sahli, Nothnagel, Penzoldt, and others), 



480 DISEASES OF THE INTESTINES 

strongly recommend it.* Summing up the experience of the latter, 
we may say that exploratory puncture is usually not a dangerous 
procedure. Puncture of the intestines cannot always be avoided. 
Penzoldt f believes he has occasionally punctured the bowel with- 
out causing any trouble. Karewski saw two injuries of the intes- 
tines from puncture during operation, which, he states, were not 
followed by deleterious effects. In another case Karewski ascribes 
a peritonitis (and subsequent operation) to puncture, but I am not 
convinced of the correctness of his statements. 

In my opinion, we should puncture only when an abscess is sus- 
pected and its presence cannot otherwise be determined. I do 
not consider it advisable to employ exploratory puncture for the 
purpose of showing the patient the necessity of an operation, for 
the patient may recover without operation — a fact which would 
place the physician in a rather awkward predicament. 

Regarding exploratory puncture, Penzoldt 30 has laid down sev- 
eral excellent rules, which we here reproduce. 

The needle must have as large a lumen as possible and still be fine, long, 
and strong enough to withstand bending. Instead of the point having the 
usual lancet-shaped tip and being sharpened laterally, it should be round and 
only sharpened at its extreme tip, so that the lower end of the needle is not 
larger than the upper, thus avoiding an unnecessarily large puncture. 

If carbolic acid, or ether and alcohol, have been used to disinfect the nee- 
dle, sterilized water should be drawn through the needle directly before punc- 
ture, because any portion of the above disinfectants remaining in the syringe 
may precipitate the albumin of the fluid aspirated and thereby give rise to 
difficulties. (For the better conservation of the cell elements, I draw sterilized 
salt solution through the syringe directly before and after aspirating.) The 
needle must fit the barrel of the syringe well. The puncture is made at the 
point of greatest resistance and dulness ; if necessary, several punctures may be 
made. After puncture of the abdominal muscles, the piston is slightly with- 
drawn; if nothing be aspirated, the needle is pushed in somewhat deeper, the 
piston being retained in the same position. The piston is then drawn out 
somewhat further, and if again nothing be aspirated, the needle is thrust 
deeper, the piston then further withdrawn, and so on till the piston has been 
drawn out its entire length. The syringe should be large enough to hold 
2 to 3 cubic centimetres, so that a large area may be explored through one 
puncture. The needle is steadied slightly with the left hand, so that it may 
follow the movements of the abdominal muscles. Puncture must never be 
performed without a microscope near at hand, so that clear fluid may be iinme- 

* [Exploratory puncture is a procedure not generally practised in the United 
States ; it is rare to find it mentioned in text-books and monographs, and when 
mentioned it is usually condemned. — Tr.] 

f Loc. cit., p. 671. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 48 1 

diately examined for cellular elements. The small amount of fluid hidden 
in the needle may be easily identified. (Where, as in private practice, especially 
in the country, a microscope is not handy, it is better to send the entire syringe 
in a properly stoppered container for examination.) 

Compared with the above diagnostic data, percussion is of sec- 
ondary importance. It is clear that in the presence of a distinct 
exudate the percussion is dull or dull tympanitic ; but if the exudate 
be situated very deeply, percussion will scarcely be of diagnostic aid. 

The same is also true of auscultation. For the purpose of differ- 
entiation between simple and septic paralysis of the intestinal mus- 
cles, Richardson m states that intestinal sounds are present in the for- 
mer and absent in the latter. The " rumbling " sound described by 
Naumann w as characteristic of abscess does not appear to have been 
observed by others. In a case without suppuration Borchardt * dis- 
covered this sound, which he considers an ordinary intestinal noise. 

5. Gastric Disturbances. — These consist in loss of appetite and 
occasionally of vomiting, especially in the beginning. In children 
vomiting is often the ushering-in symptom, and may be productive 
of diagnostic errors — e. g., acute dyspepsia, intestinal catarrh, etc. 
In the further course of the disease the vomiting generally ceases, 
but should it persist and become more marked, suspicion of severe 
invasion of the peritoneum must immediately be aroused. Should 
the vomiting become faecal in character, we must think of the 
possibility of mechanical or paralytic intestinal obstruction accom- 
panied by peritonitis. 

6. Temperature. — Temperature is of great diagnostic and prog- 
nostic importance. In simple catarrhal appendicitis the tempera- 
ture is low and falls rapidly, but in the purulent and perforative 
forms it very soon becomes quite high, and remains so for a longer 
or shorter time. To avoid repetition, we shall now discuss the 
course of the temperature in all the different varieties and stages of 
appendicitis. Rotter ffi has made a careful study of the temperature 
in the various forms of appendicitis, and although, as must be ex- 
pected from its protean type, the disease contradicts all rules and 
experience, the fever curves of Rotter are very important for the 
recognition of the status of individual cases. Rotter arranges the 
cases, according to their temperature, into five groups : 

The first group is ushered in by marked fever (up to 40° C. and 
over), with or without a chill ; after 3 or 4 days there is a tend- 

* Loc. cit., p. 330. 



482 DISEASES OP THE INTESTINES 

ency to defervescence. These cases are characterized by a smooth 
and rapid convalescence. 

In the beginning cases of the second group are not distinguish- 
able from those of the first. The fever, however, lasts longer; 
after the fifth day the temperature is not higher than 39° C. These 
cases also recover, though sometimes only after operation. 

The third group is characterized by the fact that after the fifth 
day the temperature remains above 39° C. From the time of onset 
these cases present more or less high fever, and also slight remis- 
sions followed by increase of temperature. Most of these cases 
generally run a severe course and sooner or later require operation ; 
of those not operated upon some recover and others die. 

The fourth group includes those which present a remittent type of 
fever. The initial fever is followed by defervescence, but after a few 
days the temperature again rises. This second rise indicates suppura- 
tion. Most of these cases required operation. Of those not operated 
upon, one seemingly recovered, another died of diffuse peritonitis. 

In the fifth group, which includes those with diffuse peritonitis, 
temperature has no special significance. It may be high, normal, 
or even subnormal. If a circumscribed abscess ruptures into the 
general abdominal cavity, there is a sudden fall of temperature, 
often subnormal and accompanied by collapse. 

7. Pulse. — Next to temperature, the frequency of the pulse 
and its possible irregularity are of the greatest value. There is a 
special significance in a disproportion between temperature and 
pulse. From numerous operations we know that severe peritonitis 
may exist without any rise of temperature. It is in these cases, of 
which I have observed several, that the character of the pulse 
becoines the only diagnostic and prognostic indication.* On the 
other hand, Lennander,f Karewski 22 , and others, have shown 
that in the severest cases of progressive, suppurative, fibrinous 
peritonitis, both temperature and pulse may be almost normal 
(Mikulicz). A distinct and continuously irregular, and at the same 
time very small pulse, is almost always an ominous sign. 

Finally, we would mention an interesting phenomenon pointed 
out by Mannaberg 38 , viz., the accentuation of the second pulmonary 
sound. He discovered this symptom in cases of perityphlitis 
oftener than could be accounted for by mere accident. 

* [In the United States the pulse is generally regarded as the most valuable 
single prognostic and therapeutic indicator in appendicitis. — Tr.] 
\ Loc. cit., p. 27. 



TYPHLITIS, PERITYPHLITIS .APPENDICITIS) 4£3 

(b) Appendicular Colic 

Under the name of colique appendieulawre Talamon * first de- 
scribed a clinical picture characterized by the following symptoms : 
The patient is suddenly attacked by very severe pains, occasionally 
accompanied by vomiting. The region of the appendix is extremely 
sensitive to pressure : fever is either very moderate or entirely ab- 
sent ; a tumour never forms. The attack passes off very rapidly. 
Spontaneously, or after morphin, the patients are absolutely well at 
the end of twenty-four to thirty-six hours. Talamon explains this 
condition by supposing that a faecal concretion is wedged into the 
appendix and thereby causes violent muscular contractions ; finally 
the concretion falls back into the caecum, similar to a gall-stone fall- 
ing back into the gall bladder after having reached the cystic duct. 

Von Hoehstatter 39 , Caspersohn * Goldbach 41 , Treves 17 , Xoth- 
nagel, Sonnenburg, and A. Pick 42 have described such cases. I 
have seen a large number of these cases, but in view of the sim- 
plicity of the clinical picture I shall not describe any. In my 
experience the patients are generally individuals who suffer fre- 
quently from such attacks I every four to six weeks or oftener). In 
the interval they are absolutely well, but the attacks may finally be- 
come continuous, and assume the character of chronic perityphlitis. 

All authorities agree upon the symptoms, but there is a diver- 
sity of opinion regarding the origin of this disease. Treves 17 
denies' the possibility of muscular contraction of a healthy, let 
alone a diseased, appendix, and characterizes this theory as " wholly 
ridiculous." Xothnagel admits the possibility of spasmodic con- 
traction, but does not consider it proved that coproliths wedge 
themselves into the appendix. Monod and Tanvers & express a 
somewhat similar opinion. Opposed to these theories is the cited 
case of Goldbach, observed in TVolfler's clinic in Prague. 

The patient was a sixteen-year-old scholar, •who for one year had suffered 
from jaundice and severe colicky pains under the right free border of the ribs. 
He never had fever or vomiting during the attack. Always had obstinate con- 
stipation. Later, pains were present in the evening and absent in the morning 
He now has pain in the ileo-csecal region, localized directly over 3IcBurney's 
point. Xo concretion was ever found in the stools. Palpation shows an oval. 
fairly soft tumour (caecum ?), over which may plainly be felt a second longi- 
tudinal sausage-shaped tumour. The entire mass apjDears movable, and is felt 
either in the right hypochondrium or in the lower abdominal region. Liver 

* Talamon. Appendicite et Perityphlite. Paris, 1892. p. 25 et 111 ; Colique 
appendiculaire medecine moderne, 1890. p. 837. 



484 DISEASES OF THE INTESTINES 

is not enlarged. At the operation two small faecal stones were found in the 
caecum. When these were pressed toward the appendix they easily slipped in, 
and could just as easily be forced back into the caecum. The appendix was 
absolutely normal. Extirpation of the appendix. Cure. 

This case at least proves the possibility of foreign bodies slip- 
ping into the appendix and again falling back into the caecum. It 
is very questionable whether this is a constant or only frequent oc- 
currence. From the fact that in most autopsies [and operations] 
for recurring appendicitis (which the above case greatly resembles) 
slight changes are found in the appendix, it would seem that these 
are after all very mild forms of simple catarrhal appendicitis. 

(c) Perforative Perityphlitis 

Pathological anatomy and the results of operation agree that 
perforations occur very frequently in appendicitis. It is therefore 
important to be able to diagnosticate this complication. Sonnen- 
burg gives certain symptoms as characteristic : Violent onset with 
high fever ; severe abdominal pain beginning suddenly or imme- 
diately after a meal, and very soon localized on the right side ; 
vomiting, accompanied by diarrhoea or constipation ; small, fre- 
quent pulse ; fever, rising rapidly and often ushered in by a chill ; 
marked tympanites. Patient feels extremely ill. There is slight 
cyanosis and perspiration. Distinct resistance in the vicinity of 
the suppurative area. 

The diagnosis of perforation, however, cannot be positively 
made from any of these symptoms, for suppurative appendicitis with 
tumour, severe general disturbance, high temperature, and rapid 
pulse may give a very similar picture.* 

It will therefore be wiser not to attempt to make the diag- 
nosis of perforative peritonitis, but to content ourselves with the 
diagnosis of suppurative appendicitis. 

(d) Diffuse Suppurative Perityphlitis 

According to Potter, diffuse suppurative perityphlitis originates 
in two ways : either as a purulent perityphlitis, in which the adhe- 
sions between the intestinal coils continue to extend, or by per- 
foration of a previously encapsulated abscess, whose contents spread 
over the general abdominal cavity. In both cases the pus generally 
gravitates toward the lower right side of the pelvis and Douglas's 

* [A blood count might prove of great value in differentiating the two condi- 
tions. Marked leucocytosis would speak for suppurating appendicitis. — Tr.] 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 485 

cul-de-sac ; if the process continue, the pus spreads to the left side 
of the pelvis, and from there over the different abdominal organs. 

The diagnosis of the various phases of this variety may be 
extremely difficult. Temperature, pulse, and objective symptoms 
may be deceptive, and easily lead to false conclusions. As al- 
ready remarked, if high temperature is present, it is irregular and 
remittent in character, becoming normal, again suddenly rising, etc. 
The most reliable symptom is the general appearance. The pa- 
tients are usually markedly collapsed, depressed, apathetic, the fea- 
tures are pinched and sunken, and are pale, cyanotic, and without 
congestion ; the eyes are staring ; there is absolute sleeplessness and 
anorexia ; the tongue is dry and cracked ; occasionally there is 
singultus. In a word, the patient makes a septic impression. 
To this picture there are exceptions. The patient may feel well, 
sit up in bed, his pulse and temperature be properly proportioned 
and not high, and yet laparotomy will reveal a diffuse, septic perito- 
nitis. In other cases, very grave symptoms are at first present ; 
then suddenly the patient becomes better, a the suppuration be- 
comes circumscribed" (Rotter). Contrary to expectation, the pa- 
tient recovers, perhaps only after one or several abscesses have been 
opened. Numerous other varieties are seen in practice, but a 
schematic description is impracticable, because every case presents 
special peculiarities. We have here purposely given the clinical 
picture, but not the diagnostic criteria of diffuse perityphlitis, be- 
cause after all the general impression created by the patient is the 
decisive diagnostic factor. 

The diagnosis, and I may add the prognosis, often vary ex- 
tremely, as the clinical picture changes from day to day. This 
should warn us never to give a prognosis too early in the dis- 
ease. 

2. Chronic Perityphlitis 

Chronic or recurring perityphlitis is that form in which, after a 
longer or shorter interval, renewed attacks of the disease occur. 
The American surgeons (Bull 44 , Fowler 34 , and others) designate 
this form as " recurring " appendicitis, and distinguish it from those 
cases in which the acute attack is recovered from, but a sensitive- 
ness to touch persists in the ileo-csecal region. The last form has 
been called "relapsing" appendicitis, though some, like Fenger 
of Chicago, call it " postappendicitis." 

The studies of surgeons, particularly Sonnenburg, Kiimmell, 
32 



486 DISEASES OF THE INTESTINES 

Bull, Fowler, Korte, Treves, and Senn, have given us valuable in- 
formation regarding chronic appendicitis. This disease may develop 
in many different ways. The most frequent mode is through the 
formation of partial obliterations (appendicitis obliterans, Senn) and 
strictures, with consequent stagnation of secretion, formation of cysts, 
and occasionally of empyema of the appendix. More or less exten- 
sive adhesions may develop about the appendix, and cause functional 
irregularities of the intestine, bladder, and female genitals, and pro- 
duce pain and other disturbances. The mucous membrane of the ap- 
pendix may be diseased, and small swellings and suppurations exist in 
or around the appendix ; faecal concretions are sometimes present. 
Under such conditions the appendix may perforate during a relapse. 

If we limit ourselves to the diagnosis of a diseased process in or 
about the appendix, we will scarcely ever meet with any difficulty. 
The history may give us valuable information. More important, 
however, are the typical symptoms (pain, even while at rest, but in- 
creased by motion or straining ; constipation) and the discovery of 
a circumscribed area of sensitiveness to pressure, and of infiltrations 
about the caecum or appendix. 

In recurrent perityphlitis the patients have no symptoms be- 
tween the attacks. From time to time, either without recognisable 
cause or after strains, errors in diet, colds, or constipation, the 
pain recurs, a palpable tumour in the appendix region, accompanied 
by fever, nausea, and vomiting, appears, and in about one half the 
cases perforation occurs. 

As Treves has pointed out, and as is generally known, the recur- 
ring attacks are usually not as severe as the primary one. In recur- 
ring appendicitis perityphlitic abscesses seem to develop very rarely. 
Talamon * records a case in which an abscess, necessitating surgical 
treatment, developed in each of four attacks. 

In the vast majority of instances the proper diagnosis can be 
made from the symptoms above enumerated. The diagnosis is 
difficult only in those cases in which appendicitis must be distin- 
guished from disease of the female genitals. We shall discuss this 
under differential diagnosis. On the other hand, it is almost impos- 
sible to diagnosticate the individual pathological conditions in and 
about the appendix ; it would therefore be useless to enter into a 
discussion of the diagnosis of this point, which, moreover, is of 
little practical value. 

* Loc. cit., p. 151. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 487 

Differential Diagnosis 

The diagnosis of a typical case of appendicitis is simple ; it may 
become quite difficult when the disease runs an irregular course, or 
when the patient is first seen during the late stages of the disease. 
It is impossible to consider all the numerous differential possibili- 
ties ; in the following we shall discuss only the important ones. 

Simple appendicitis gives rise to the least difficulty. Mis- 
takes may occur if the pain is atypically localized, or if the objec- 
tive symptoms are entirely or almost entirely absent. 

In the former instance (i. e., the atypical location of the pain) 
we must consider biliary and renal colic, and occasionally mucous 
colic. In most cases careful observation will scarcely leave room 
for doubt. According to J^aunyn, the examination of the urine 
for indican may be of value. Naunyn 45 states that indican is 
never absent in appendicitis, while in biliary colic it is only occa- 
sionally present. As another important diagnostic fact, it must be 
mentioned that in cholelithiasis the posterior surface of the liver, 
between the tenth and twelfth dorsal vertebrse, two to three finger- 
breadths to the right of the vertebral column, is sensitive to pressure. 
In nephrolithiasis, it will be necessary to carefully palpate the right 
kidney and to examine the urine. 

In children, and sometimes in adults, appendicitis may be con- 
founded with " febrile gastro-enteritis." Karewski ^ in particular, 
has directed attention to these errors, and every physician will 
appreciate his warning. If, as a. result of this error, these cases 
are treated with calomel and castor oil, serious danger may arise. 
In children, in all cases of so-called febrile gastro-enteritis accom- 
panied by acute pain, we should at once think of appendicitis. If 
we then err, there can never occur the severe consequences that 
may otherwise arise. 

The diagnosis is far more difficult if the sensitiveness to pressure 
or an exudate is localized, not at McBurney's point, but at other 
places — e. g., in the right or left hypochondrium, the umbilical 
region, the left iliac fossa, etc. 

The experiences of surgeons, particularly the oft-quoted topo- 
graphical clinical studies of Curschmann, have shown us how the 
caecum and the appendix may be found in various situations. In 
one case, close to the right costal border, Curschmann 46 found a 
hard superficial tumour the size of the palm of the hand. The 
tumour lay in front of the intestines, and was connected with the 



488 DISEASES OF THE INTESTINES 

inner surface of the abdominal wall. Judging from its origin, posi- 
tion, and form, it was a peritonitic exudate. The patient died of 
general peritonitis. At the autopsy the caecum was found turned 
up in front of the descending colon, with the appendix touching the 
liver (see Fig. 25). 

I herewith present a similar case described by Rotter : 

A man, fifty-one years old, while under ambulatory treatment at Kissingen, 
became ill with gangrenous appendicitis. Eight days after the onset of the 
disease a tumour was found between the liver and the ascending colon. The 
most striking feature was the great mobility of the tumour ; it could easily be 
moved across the middle line toward the left, whereas perityphlitic tumours in 
general are diffuse, and attached to the posterior abdominal wall. 

The diagnosis rested between a tumour of the colon and of the 
kidney till an exploratory puncture showed feculent pus. The great 
mobility of the tumour was due to the fact that it was not adherent 
to the anterior or posterior abdominal wall, bat rested upon the right 
side of the mesentery of the small intestine, the remainder of the 
abscess wall being formed by coils of adherent intestine. In dis- 
placing the tumour, the mesentery and adherent bowel moved 
with it. 

In his Clinic of Cholelithiasis, Naunyn mentions similar in- 
stances. Almost all experienced surgeons (particularly Sonnenburg, 
Lennander, Fowler, Korte, and Riedel) have reported similar cases. 
The practical conclusion to be drawn is that, although an exudate or 
localized sensitiveness be found in other than in the typical situa- 
tion, we must always keep in mind the possibility of appendicitis. 

Cases of pericolitis and sigmoiditis (later to be described) show 
that inflammatory exudates, though indeed more rarely, may occa- 
sionally originate from other sources than the appendix. 

Exploratory puncture may be of diagnostic value. The with- 
drawal of feculent pus indicates a perforating appendicitis. 

It may be very difficult to differentiate between inflammatory 
disease of the female adnexa and appendicitis. The differentiation 
may be impossible when, as often happens, appendix and adnexa are 
simultaneously diseased. I have seen several cases of this kind. 
Accumulations of pus in Douglas's pouch may also give rise to diag- 
nostic errors. Borchardt thinks that the differentiation can be made 
by examining the pus for bacterium coli communis, the presence of 
which would speak for appendicitis. 

For further details of the subject the reader is referred to the 
monograph of Sonnenburg. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 489 

The differential diagnosis is quite difficult where the appendix is 
in the small pelvis and there gives rise to an abscess. In these in- 
stances the differential diagnosis between appendicitis and inflamma- 
tory disease of the adnexa can rarely be made. 

Tumours, particularly of the caecum, may be mistaken for 
chronic appendicitis, and, much more infrequently, for acute appen- 
dicitis. The tumours here to be considered are sarcoma, carcinoma, 
actinomycosis, tubercular tumours of the caecum, occasionally also 
ileo-caecal invagination. 

For purposes of differentiation, Sonnenburg 47 recommends infla- 
tion of the intestines. In perityphlitic exudates the intestines be- 
come distended, in neoplasms they remain rigid. The mobility of 
a questionable tumour speaks decidedly against an exudate ; but 
immobility does not speak against neoplasms, since they may be 
fixed by adhesions. Where symptoms of stenosis of the large 
bowel are present the diagnosis may be easy. If these be absent, 
the insidious course, the cachexia (in malignant tumours), the pres- 
ence of blood or pus in the stools, will indicate the correct condi- 
tion. Reports of cases show, however, that numerous errors are 
made which are only cleared up by operation or autopsy. (Com- 
pare with chapter on Intestinal Carcinoma.) 

Finally, we have the rare occurrence of the inflamed appendix in 
a hernial sac (inguinal or femoral canal) which has resulted from 
foetal maldevelopment. This may occur on the left as well as on 
the right side. These cases run their course as incarcerated her- 
niae, and are of great surgical interest. The diagnosis is almost im- 
possible. 

Appendicitis in the stage of diffuse peritonitis may cause con- 
siderable diagnostic difficulty. This originates under very differ- 
ent circumstances. In the first place, diagnostic confusion may be 
present when, in the midst of apparently normal health, or after 
obscure premonitory symptoms, signs of perforative peritonitis 
appear. It is difficult to determine the cause of the condition and 
the proper site for the surgical incision, upon which considerations 
the life of the patient may depend. In the chapter on Duodenal 
Ulcer (page 293) we have seen that not infrequently a perforation 
of the appendix is sought for, and autopsy reveals a perforating 
duodenal ulcer. 

Regarding the differentiation between perforations of duodenal 
or gastric ulcers and perityphlitic abscesses, Marmaduke Sheild 48 
ascribes great value to the faecal smell of the pus and the gas bub- 



490 DISEASES OF THE INTESTINES 

bles formed ; these would indicate disease of the appendix and 
caecum. He also lays stress upon the reaction of the pus, which is 
neutral or alkaline in appendicitis, and acid in the others. Mistakes 
like the above will never be unavoidable, but they warn us not to 
operate till the site and nature of the perforation have been deter- 
mined with some degree of certainty. 

I believe that the prominence given to perforative appendicitis 
tends to keep all other etiological factors in the background. 

What is true of duodenal ulcer is also true of gastric and the 
other numerous and genetically different forms of intestinal ulcers. 
The differentiation between perforating ulcer of the caecum and 
of the appendix can only exceptionally be made. In sudden per- 
foration this distinction naturally has no practical significance. 

"We are frequently called upon to differentiate between appen- 
dicitis and intestinal obstruction. In the following section we shall 
discuss chronic obstruction as a complication of appendicitis. In the 
cases there cited the diagnosis was easy, since the previous attack of 
appendicitis clearly indicated the original trouble. In acute cases 
the differentiation is much more difficult. (Compare also the chap- 
ter on Intestinal Obstruction, page 368.) The symptoms may be 
due to a variety of causes. The intestinal obstruction may result 
from reflex intestinal paralysis, from compression of a perityphlitic 
exudate, from kinking produced by adhesions, or from any other of 
the almost innumerable ordinary causes. If no palpable abscess be 
present, the history not definite, the temperature normal or almost 
so, the patient collapsed and vomiting faeces, I see no possibility of 
distinguishing between perityphlitis and obstruction. The situation 
is the more critical since the circumstances necessitate quick de- 
cision, and do not allow of careful and thorough examination and 
observation. 

In these instances the laparotomy will clear up the diagnosis. 
We must again emphasize the value of a careful history, which 
may offer an etiological hint and enable us to reach the proper 
diagnosis. The history does not entirely guard against error, as 
proved by a case of Sonnenburg 47 , in which the history indicated 
perityphlitis, but laparotomy showed obstruction by gallstones. It 
is hardly necessary to state that the above diagnostic difficulties do 
not always exist, and that when the symptoms are typical the diag- 
nosis may be made at sight. 

Typhoid fever, particularly after perforation, and intestinal 
tuberculosis may also be confused with perityphlitis. When com- 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 491 

plications exist, intestinal tuberculosis can be differentiated with 
difficulty from perityphlitis. Borchardt 10 reports a case of this 
kind. 

The patient entered the hospital with a pleuritic effusion and diarrhoea. 
Tuberculosis was diagnosed. During an illness of three weeks, symptoms 
pointing to the appendix were so mild that they were overlooked. Before 
death peritonitis occurred, which was shown by the autopsy to have originated 
from a perforated appendix. 

Where the local symptoms are obscure, the pain not well local- 
ized, and the fever curve of a continuous type, we must think of 
typhoid fever. All the characteristic symptoms of typhoid must 
naturally be considered, and the Gruber-Widal serum test made.* 
The differentiation between typhoid fever and perforative peri- 
tonitis may be very difficult, especially in recent cases with obscure 
symptoms. 

Septic (cryptogenetic) forms of appendicitis may also give rise 
to diagnostic errors. As shown by the cases of Heubner 49 and 
Karewski ^ the symptoms are generally not . sufficiently well de- 
fined, and the course of the disease so violent that the patient dies 
before all diagnostic possibilities can be excluded. 

The cases of " pseudo-peri typhlitis " (Nothnagel) and " appendi- 
citis larvata" (Ewald) should also be mentioned. French observers 
(Talamon 26 and Kendu 50 ) have described cases of hysterical perito- 
neal irritation which very closely resemble appendicitis, and which 
have been operated on. Nothnagel 51 has recently described a simi- 
lar clinical picture under the name of " pseudo-perityphlitis." Un- 
der the name of "appendicitis larvata," f Ewald 52 has described a 
train of symptoms in which (as proved by subsequent operations), 
despite apparent hysteria, distinct changes occur in the appendix. 

Complications 

These are not infrequent. They may obscure the clinical pic- 
ture, and, after the patients have passed through the actual attack, 
often cause death. 

Bossard aptly compares the inflamed appendix to a bomb which 
may explode at any moment. The comparison is still further true 

* [The blood must also be examined for leucocytosis, which is absent in typhoid 
fever and present in appendicitis and suppuration. — Tr.] 

f As correctly stated by many authorities (Gussenbauer, J. Israel, and Senator), 
the designation " appendicitis larvata " may easily produce misunderstanding, be- 
cause it contradicts the fact that all the clinical data are present. 



492 DISEASES OF THE INTESTINES 

in that it indicates the many different directions in which such a 
bomb may burst. 

All complications arise in two ways : by means of thrombosis 
and embolism, or by extension of the inflammatory process by con- 
tiguity. The latter is decidedly the more frequent. As we have 
already seen, the perityphlitic process spreads most rapidly down- 
ward (forming pelvic and vaginal abscesses). It may also spread pos- 
teriorly (causing lumbar abscesses, vertebral abscesses, etc.), toward 
the diaphragm (subphrenic abscesses), toward the anterior abdominal 
wall, the hollow viscera, and even into the thorax. If rupture 
through the abdominal or thoracic wall takes place, a fistula may 
result. It is not our purpose to discuss all the clinical symptoms 
arising from these complications. The resultant conditions are un- 
derstood with difficulty when weeks or months intervene between 
the primary disease and the secondary complications 53 , especially 
when the perityphlitic attack itself runs an exceedingly mild 
course. 

G-erhardt M in particular has called attention to the frequency of 
pleurisy as a complication of appendicitis. He has observed it 
in no less than forty-eight per cent of all cases of appendicitis. 
In the great majority (forty-two out of fifty) the pleurisy was on 
the right side, in seven cases on both sides, and only once on the 
left side. The pleurisy was generally serous ; in a small number 
there was dry pleurisy. These cases are most probably explicable 
by the fact that the inflammatory process affects the retrocecal 
connective tissue ; from here the process continues upward through 
the lymph spaces of the retroperitoneal cellular tissue, advancing 
through the diaphragm to the right pleura. 

The second class of complications originate through thrombosis 
of the appendicular vein. Thence the thrombotic particles are swept 
into the blood stream and reach a branch of the portal vein. Pyle- 
phlebitis and multiple liver abscesses develop, and, as observed by 
Genclron 5D , an abscess may rupture through the diaphragm, causing 
suppurative pleurisy and pericarditis. Terrillon m has directed at- 
tention to purulent pleurisy as a comparatively frequent complica- 
tion of appendicitis. Thrombi may become loosened from some of 
the branches of the inferior vena cava and be carried as emboli to 
the heart and lungs. 

Thrombosis of the iliac or femoral vein is a rare complication. 
These thrombi originate through direct extension of the inflam- 
matory process to the large venous vessels, or as the result of stasis 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) ±93 

following compression. Under these conditions, as shown by Fow- 
ler, fatal haemorrhages may occur. Arterial thrombosis is very 
rare. Korte l0 has reported one case. Bull and Fowler 57 have pub- 
lished cases of rupture of abscesses into the iliac and femoral 
arteries. Most of these conditions can be diagnosticated only on 
the autopsy table. The cases of suppurative hepatitis, pleurisy, and 
pericarditis, already mentioned, may be recognised during life, 
but we are rarely able to establish the relation between them and 
the causative appendicitis. 

An important complication of appendicitis, to which attention 
was called by Rotter 32 , is chronic intestinal obstruction by angular 
kinking of the intestine in consequence of adhesions. Two cases 
were cured by division of the adhesions. A case of this kind, com- 
plicated by numerous abscesses, was observed and brilliantly diag- 
nosticated intra vitam by Nothnagel 58 . 

The infrequent complication of pregnancy with perityphlitis 
will be briefly discussed. Gynecologists (Abrahams, Munde, Hla- 
wacek, Treub, McArthur, Marx, E. Frankel 59 , and others) teach, 
that appendicitis during pregnancy is generally a very serious com- 
plication. Fowler claims that this complication always leads to 
abortion, miscarriage, and death. E. Frankel regards this as too 
pessimistic. As the result of his own observations and a study of the 
literature of the subject, he has demonstrated that the gravity of 
this condition depends upon the variety and severity of the appen- 
dicitis. In mild cases the process may heal and the pregnancy run 
its natural course ; in severe cases, localized or general peritonitis 
will produce abortion and generally the death of the mother.* The 
puerperal period may also be endangered by appendicitis. Accord- 
ing to Frankel, there are three possibilities : 1. In consequence of 
uterine contraction there is a break in the continuity of the peri- 
appendicular abscess wall, with subsequent rupture into the free 
peritoneal cavity and general peritonitis. 2. Fresh invasion of a 
former inflammatory area by the bacterium coli. This invasion 
may produce peritonitis as well as puerperal infection of the uterus. 
3. Parametritis may develop from extension of the appendiceal 
process to the vessels coursing in the appendiculo-ovarian liga- 
ment (Clado and Durand), or in the retrocecal tissue. In a case 

* [Successful operations for appendicitis during pregnancy with subsequent 
delivery at term have been reported by Kraft 78 , McCosh 19 , Johnson 80 , Gerster 81 
(two cases), and others. An instance of recovery without operation and subse- 
quent delivery at term has been published by Bayley 82 . — Tr.] 



.494 DISEASES OP THE INTESTINES 

of probable induced abortion which came under my observation 
there occurred a severe appendicitis, which was cured by operation. 

Treatment 
Typhlitis 

I believe that, therapeutically as well as diagnostically, typh- 
litis should be considered apart from appendicitis. The treatment of 
these two affections is so entirely different that a separate descrip- 
tion is necessary. We have previously (page 431) discussed the 
different forms of development of typhlitis. Most of these are 
mainly of surgical interest, and their treatment is practically that 
of appendicitis, to which we therefore refer the reader. Medical 
practitioners are principally interested in stercoral typhlitis. If the 
physician agrees with us that, although very rare, stercoral typh- 
litis does occur, the therapeutic methods to be used become obvious. 

The main treatment consists in the removal of the impacted 
faeces. We should employ therapeutic methods which . even in 
appendicitis do no harm, for it is impossible to always exclude the 
latter disease. As already mentioned (page 189), I am decidedly 
opposed to the administration of laxatives. For the purpose of 
softening the faeces I use cleansing enemata of oil, or mixtures of 
castor oil, cod-liver oil, and soda. In severe cases intestinal irriga- 
tion (page 179) may be used. By these means we generally suc- 
ceed in softening the inspissated faecal masses. 

Should satisfactory evacuation follow these procedures, the intes-. 
tine will require rest. For the reasons often stated, I would warn 
against repeated enemata in the expectation of more thoroughly 
cleansing the caecum. On the contrary, after the patient has had a 
movement the bowels should be constipated by opium suppositories 
(0.02 to 0.03 gms. [of the extract?]) or tincture of opium (twenty 
drops given once). Some benefit may also be derived from cold 
compresses. After three or four days, when the subjective pain 
and the sensitiveness of the caecum have ceased and the patient's 
general condition is satisfactory, another enema may be given. 

During the inflammatory stage the diet must be fluid, and gradu- 
ally increased as the inflammation subsides and disappears. Subse- 
quent treatment consists in preventing faecal accumulations ; when- 
ever possible, this is to be accomplished by dietetic means only, 
aided perhaps by mild laxatives, or still better by enemata. In this 
connection we refer the reader to the chapter on Constipation. 



TYPHLITIS. PERITYPHLITIS (APPENDICITIS) 495 

There still remains an important question : Shall patients with 
this form of typhlitis remain in bed ? Most decidedly they should. 
The patient is allowed out of bed only when three days have passed 
without pain, fever, or gastric disturbances, when the general con- 
dition is good, and there is no longer sensitiveness to pressure in the 
ileo-cgecal region. After he has left his bed the patient must be 
advised to take care of himself for several days. 

Perityphlitis 

(a) Acute Perityphlitis 

A few observations regarding the possible prophylaxis of peri- 
typhlitis will not be out of place. As far as I know, Sahli, in his 
Congress Report, was the first to touch upon this subject. It was 
later taken up and discussed by Penzoldt 30 , and more recently by 
Ewald 60 . Authors are fairly well agreed that, to prevent a relapse 
and to provide against an attack of appendicitis, constipation must be 
controlled. Where family predisposition toward appendicitis exists, 
I agree with these conclusions. As regards care to prevent the swal- 
lowing of seeds, fish and other bones, I consider these precautions 
theoretical rather than practical. The findings of surgeons in ap- 
pendicitis operations do not justify such precautions. As previously 
mentioned, foreign bodies are found only in a small number of cases. 

The treatment of perityphlitis requires some preliminary re- 
marks, by which we hope to make our general standpoint more 
clear. There is no doubt that autopsies and operations have 
already produced a reaction in the treatment of appendicitis. This 
reaction will certainly become greater in the future. 

Thanks to a large literary and statistical material bearing upon 
the subject, the condition of the appendix and its surroundings can, 
in the majority of cases, approximately at least, be determined by 
abdominal palpation. * This distinct advance in diagnosis lends aim 
and direction to present therapeusis, and at the outset demands 
neither surgical nor internal therapy, but simply a plan which will 
always keep in mind the anatomical relations of the diseased pro- 
cesses and their influence upon the general system. This stand- 
point permits at times a surgical view of the case on the part of the 
medical practitioner, and vice versa. In the therapy of appendicitis 
internal and surgical treatment should not and cannot be opposed ; 
but when internal measures do not suffice, surgical intervention 
should be .an aid to them. 
* [In the United States the opposite opinion prevails. Compare p. 509, 1. 3, etc. Tr.] 



496 DISEASES OF THE INTESTINES 

The internal treatment, which we shall now consider, must be 
based upon the following principles : 

1. Absolute bodily rest. 

2. Rest of the intestines. 

3. Appropriate diet. 

Absolute rest in bed is one of the oldest and most important thera- 
peutic laws. From the moment appendicitis is diagnosticated the 
patient must take to bed, and not leave it until the attack is entirely 
over. Simple as are these regulations, they are frequently broken, 
generally by the patient, but sometimes by the physician. In his 
excellent treatise Rotter has reported a number of serious results 
from non-observance of these simple rules. 

The most important remedy in perityphlitis is opium, which was 
first employed by Yolz. It has a very pronounced immobilizing 
action on the intestines, reducing their movements and reflex irrita- 
bility to a minimum. In this manner salutary adhesions may form, 
the peritonitis become circumscribed, and, according to Sahli, the 
shock of the peritonitis be lessened. Opium has a favourable effect 
upon vomiting, loss of sleep, muscular irritability, and, according 
to Penzoldt, it also lessens the thirst. Finally, I would call atten- 
tion to the little-known diuretic action of opium, which, in view of 
intestinal decomposition, is not without importance. In the General 
Division (page 195) we have already given the underlying princi- 
ples of the opium treatment of appendicitis ; we shall here briefly 
repeat them. 

In the first days of appendicitis, when pain, fever, and an in- 
creasing tumour are the most prominent symptoms, opium is espe- 
cially appropriate. It should be administered systematically (tinct. 
opii, gtt. xx, every three hours ; or ext. opii, 0.03 gm., t. i. d.). 
Suppositories of opium, each containing 0.05 gm. ext. opii, to be 
used t. i. d. ? are also applicable, especially where internal adminis- 
tration causes nausea or vomiting. Provided a good and active 
preparation be at hand, the same directions apply to opium given 
subcutaneously (ext. opii, aquos. sterilizat., 0.3 gms. in 10.0 c. cm. — 
dose, a Pravaz syringeful t. i. d.). 

In opium therapy the main rule must be avoidance of its lavish 
use. When the process has reached or passed its highest point and 
defervescence begins, opium is to be discarded. I would especially 
warn against giving opium during convalescence. There is no 
apparent reason for continuing the drug, and it may produce intes- 
tinal paresis, from which the patients often suffer for the remainder 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 497 

of their lives, particularly, as is so often the case, if there had been 
a tendency to constipation. 

Opium is indicated not only in the beginning of the disease, but 
also iu suppurative and perforative appendicitis and in marked diffuse 
peritonitis. In these instances the doses must be increased until 
the pulse is slow and full, the general condition satisfactory, and the 
facies composed (page 195). In beginning collapse and in sepsis 
opium is without effect ; in fact, it must be changed for the exci- 
tant class of remedies. 

Some authors prefer morphin (subcutaneously) to opium. The 
advantages of opium are quite evident. The treatment of appen- 
dicitis with preparations of belladonna, which has also been recom- 
mended, has not yet been sufficiently tested. Ferrand 61 prefers bella- 
donna to opium ; he claims it has all the advantages and none of 
the disadvantages of opium (suppression of intestinal secretion, fae- 
cal accumulations, increase of putrefaction). The few cases I have 
treated with belladonna are not sufficient for me to express an opin- 
ion of its effect. 

The contraindication to laxatives of all kinds follows directly 
from the principle of absolute intestinal rest. In fact, there is sel- 
dom occasion for a laxative. If such necessity should arise, an 
oil enema is by far the most appropriate remedy ; in these cases, 
as Penzoldt quite correctly recommends, the physician should give 
the rectal injection himself. 

It need not be emphasized that the greatest possible precautions 
are required during the act of defecation. 

Ice applications [in the form of the ice bag or the Leiter coil] 
to the ileo-caecal region constitute a further immobilizing agent, 
for the patient is then forced to lie absolutely quiet on his back. 
The ice may also lessen the pain. We need not fear peristalsis 
from the cold applications, for daily experience has shown that 
this, in view of the powerful inhibitory action of the opium, is 
scarcely to be considered. 

Ice is indicated as long as inflammatory symptoms continue and 
no fluctuating abscess has formed. In the latter instance ice is, to 
say the least, superfluous. The physician is often asked whether 
ice applications are to be continued during the night. This question 
cannot be answered generically. If sleep be thereby hindered, the 
ice may be removed and cold applications instead applied ; other- 
wise there is no objection to the continuation of the ice during the 
night. 



498 DISEASES OF THE INTESTINES 

As regards diet, the principle of greatest possible intestinal rest 
also applies. This finds its extremest exemplification in absolute 
starvation during the stage of inflammation. I do not deny the 
theoretical justification of the absolute withdrawal of food, but, as 
already stated (page 154), I believe that it is too severe a measure. 
It is justifiable only in an etiologically obscure case of peritonitis or 
of intestinal obstruction with fgecal vomiting. In these instances, 
subcutaneous injections of salt or sugar solutions are the only means 
of subsidiary nourishment, but, with Penzoldt and Ewald, and as 
opposed to Treves, I do not, for obvious reasons, consider nourish- 
ing enemata indicated. 

The most important dietetic details have been described in the 
General Division ; we can scarcely add to that description. 

Besides treatment of the perityphlitic attack, many cases require 
appropriate after-treatment or observation. Regulation of the bow- 
els in particular demands attention. In this connection we refer to 
the recommendations given in the chapter on Chronic Constipation. 
After the acute attack has passed, inflammatory adhesions or more 
or less exudations may remain ; the question then arises how these 
may be best removed. In recent cases I think it wisest to treat 
these exudations expectantly, and to advise rest and general bodily 
care. If the swelling persists, artificial or natural saline or mud 
baths are often beneficial, or even curative. 

Massage is also often advised for the exudations following peri- 
typhlitis. We have stated in the General Division that massage is 
to be used only after the inflammatory symptoms have run their 
course, and must be practiced only by a physician experienced in 
this field of work. Other authors (e. g., Nothnagel) advise against 
massage. 

The question regarding gymnastics and sports must be carefully 
decided. This question is the more apt to arise because appendi- 
citis usually occurs at an age when exercise is an important factor. 
May a military officer ride, a gymnast exercise, a bicyclist ride, an 
oarsman row ? These questions must be answered individually and 
with the greatest reserve. Under all circumstances, and for at least 
several months, exercises like the above should be prohibited. If no 
relapse occurs and no untoward symptoms set in, we may tenta- 
tively allow the patient to follow his special sport. Mountain 
climbing, either as a vocation or as a pastime, requires the greatest 
caution, and should not be extensively attempted for at least six 
months after the attack. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) ^99 

"We have spoken of the use of baths, particularly of saline and 
mud baths, in the after-treatment, especially where there is consti- 
pation. These may be combined with water cures (Kissingen, 
Homburg, Marienbad, Carlsbad, Tarasp, Franzensbad, Eohitsch, 
Elster, etc.). [For corresponding American mineral springs and 
wells, see page 161. — Tr.] (Compare also the chapter on Hydro- 
therapeutics in the General Division.) 

Operative Treatment 

In view of the newness of the operative treatment of appendi- 
citis, and of the customary separation of internal and surgical ther- 
apy, it is quite difficult for the internal practitioner to express an 
opinion concerning the indications for and the significance of 
operation. Our judgment will therefore depend upon the ex23eri- 
ence of surgeons who are acquainted with the results that can be 
obtained by internal treatment. 

At every one of the numerous discussions within recent years 
there has arisen the preliminary question : How do the results of 
internal treatment compare with those of surgery ? Sahli, Ren- 
vers, Kleinwachter, Hotter, Curschmann, Aufrecht, and others, have 
brought forward a very impressive material to show the curative 
results of conservative treatment. They have thus doubtlessly 
strengthened the cause of conservatism, and have contributed much 
toward preventing too radical surgical measures. 

We quote Sahli's statistics, because they are very large and 
therefore most trustworthy. Sahli 1 collected the entire material 
of Swiss physicians, and thus gathered 7,213 cases. Of these, 
473 were operated on, with a mortality of 21 per cent ; 6,740 were 
treated conservatively, with a mortality of 8.8 per cent. Relapses 
occurred in 20.8 per cent. The figures of other medical practi- 
tioners and surgeons only partly agree with these. For instance, 
Kleinwachter gives a mortality of 7 per cent ; Curschmann and 
Aufrecht of 4 to 5 per cent ; Rotter, 8.9 per cent ; Renvers only 3 
per cent. The same is true of surgical statistics, which give a 
varying mortality between 9.6 per cent (Murphy) and 24 per cent 
(Richardson), the average being about 15 per cent. It is possible 
that the mortality will be lowered by increased experience, early 
operation, etc., but a mortality of 5 to 8 per cent will exist in ap- 
pendicitis operations, no matter how timely and successfully the 
operation is performed (Rotter). 

It is useless to compare the mortality rates of internal and sur- 



500 



DISEASES OF THE INTESTINES 



gical treatment. We might at most compare the several groups of 
appendicitis with each other (simple appendicitis, suppurative, 
perforative, with or without diffuse peritonitis, etc.). Aside from 
this consideration, as recently emphasized by Borchardt, the value 
of statistics in determining the good obtained from one or the 
other method of treatment is extremely doubtful.* There are too 
many incommensurable quantities to be considered, which in some 
manner must lead to a false conclusion. After all, the comparison 
of hospital death rates would seem the most reliable. Even here 
great differences exist. Thus, as the result of internal treatment in 
the St. Hedwig Hospital [Berlin], in 213 cases of appendicitis, 
Rotter gives the low mortality of 8.9 per cent. In the internal 
division of the Urban Hospital [Berlin] the mortality of appendi- 
citis (132 cases) was about 12 per cent (Borchardt 10 ), but of the 16 
that died, about 14 were admitted with an inoperable general 
peritonitis. These statistics speak for themselves, and demon- 
strate that even the cases which come under the observation of 
one man are subject to many accidental variations. From this it 
follows that special rules for individual cases cannot be laid down, 
but that only underlying general principles can be given. 

For the purpose of clearness we employ the usual subdivisions 
of appendicitis into simple catarrhal, suppurative, and perforative. 
We shall later, from the surgical standpoint, discuss chronic peri- 
typhlitis. 

Simple catarrhal appendicitis does not usually necessitate sur- 
gical interference. Sonnenburg believes that in these instances 
the perityphlitic attack, and not the perityphlitic process, is cured. 
There is not, however, any ground for such conclusion. Simple 
perityphlitis will always be a medical disease. 

In circumscribed suppurative appendicitis we must distinguish 
between cases with and those without abscess. In the former group 
there exists a possible indication for operation. When the patient's 
general condition is good we may await the absorption of the exu- 
date, which undoubtedly takes place in a large number of cases. 
At all events the operation is generally simple, without danger, and 
usually cures the suppurative process in a short time. 

It is quite a different question whether the appendix itself 
should be removed in suppurative appendicitis. Surgeons hold 



* Compare also the brilliant discussion of 0. Rosenbach regarding the value 
of statistics in diphtheria, in the Munch, med. Wochenschr., 1898, No. 27. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 501 

contradictory opinions on this subject. As far as I can see, Son- 
nenburg is the only German surgeon who recommends radical ex- 
tirpation in order to prevent relapses. Fowler and Murphy are of 
the same opinion. The majority of the other surgeons — Korte 10 , 
Schede 6 ' 2 , Rotter 32 , Mikulicz 63 , etc. — consider that simple incision is 
the proper procedure, because the removal of the appendix is very 
dangerous and sometimes technically impracticable. In a case of 
Gerhardt's w , after extirpation of the appendix there was a relapse. 
The appendix may be removed when the patient is not thereby en- 
dangered — i. e., when the abscess is very small and well encapsu- 
lated, and also in those cases where the appendix is not walled off 
by adhesions from the general peritoneal cavity.* 

Experimental studies (Wieland 65 , P. Grawitz 66 ) have demon- 
strated that the peritoneum is capable of absorbing small quantities 
of pus. Furthermore, Renvers has seen cases in which the pres- 
ence of pus was shown by exploratory puncture, cured by con- 
servative treatment. Finally, during operations, inspissated pus, 
evidently from previous exudates (Kummel, Korte, and others), is 
often found in and around the appendix. 

In addition to the above, pus may be eliminated in two ways : 
(1) By self -drainage (Sahli) — that is, by the pus emptying through 
the ostium of the appendix itself ; or (2) by perforation of an extra- 
appendicular abscess. Pus can only rarely be discovered in the 
evacuations of the patients, but this fact does not speak against 
the theory of self -drainage, since pus in the stool soon undergoes 
changes which may make its recognition impossible (Sahli). On 
the other hand, extension of the suppurative process with diffuse 
peritonitis is quite frequent. These cases are often cured by sur- 
gical, and only exceptionally by conservative, methods. The ques- 
tion is still further complicated by the fact that, according to Rot- 
ter, even with general peritonitis the inilammatory process may 
become localized, lead to the formation of an abscess, and therefore 
heal spontaneously or after simple incision. 

These complicated conditions make the decision regarding the 



* [The operator will have to be guided by the condition present. Among 
American surgeons, Dearer 83 and Morton S4 favour the removal of the appendix 
in every instance. McBurney 85 , Bull 86 , Senn 87 , Murphy 88 , Mynter 89 , Fenger 90 , 
Fowler 34 , and almost all other noted surgeons advocate a careful search for and 
removal of the appendix when the patient's general condition permits of reason- 
able delay, and when the location and extirpation of the appendix do not neces- 
sitate dangerous dissection and endanger the continuity of the abscess wall. — Tr.] 



502 DISEASES OF THE INTESTINES 

time for surgical intervention one of the most difficult and respon- 
sible tasks of the physician. Should we operate while there is still 
hope that the process will heal under conservative treatment ? 
How long should conservative treatment be tried ? We must not 
forget the deceptive similarity between convalescence and danger. 
What shall determine the proper procedure in these cases : the un- 
favourable result of internal treatment, or the successful results of 
surgery ? Not a few cases have been reported in which, both under 
conservative and surgical treatment, the disease unexpectedly took 
a favourable or an unfavourable termination. 

As a general principle for these cases, we would lay down Rot- 
ter's rules regarding the course of the temperature. He says : " If, 
despite proper internal treatment, the fever shows no tendency to 
subside, or rises after the third day, or if, after a slight remission, 
the temperature after the fifth day reaches 39° C. or over, opera- 
tion should not be delayed." In such cases the patient's general 
condition will usually be disturbed, and the seriousness of the con- 
dition will be indicated by the vomiting, the frequent, soft, irregu- 
lar pulse, tympanites, great bodily weakness, sleeplessness, marked 
sensitiveness to pressure in the ileo-csecal region, and singultus. 
Rotter also says that cases which at first run a favourable course, 
but which after a number of days again have fever, should also be 
operated on. In all these instances an abscess is present, and if not 
incised may lead to serious complications. 

Those cases which immediately, or after twenty-four to forty- 
eight hours, have signs of diffuse septic peritonitis, are undoubtedly 
surgical, and the sooner they are placed under the surgeon's care 
the better. Here, as already mentioned, the great difficulty fre- 
quently lies in the diagnosis. The majority of these patients can 
scarcely stand narcosis, let alone operation ; hence the surgical re- 
sults are not very encouraging. Thus, despite timely operation, 
Rotter lost sixty-six per cent, Korte sixty-four per cent, and Son- 
nenburg 67 fifty-eight per cent of such cases. Every successful re- 
sult must be regarded as a direct gain. 

(b) Chronic Perityphlitis 

Concerning this affection a proper understanding is beginning 
to exist between medicine and surgery. We have already studied 
the two forms of chronic appendicitis : chronic appendicitis in its 
narrower sense, and relapsing appendicitis. Under certain condi- 
tions both forms may be accompanied by severe symptoms, which 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 593 

disturb the patient and interfere with his ability to do work, or 
even endanger his existence. 

AVe must, however, remember that great care and the use of 
appropriate remedies (baths, springs, and diet) will remove many 
of the patient's symptoms, and that relapses are often much milder 
and do not last as long as the primary attack. Finally, as Rotter ffi 
and Kummell 68 have shown, relapses are much more frequent 
within the first year following the primary attack, decrease in fre- 
quency in the second and third years, and are very rare thereafter. 
The results of surgical treatment are exceptionally favourable; 
Kummell ^ , who has had the most experience in relapsing appendi- 
citis, does not consider removal of the appendix more dangerous 
than an ordinary ovariotomy. 

The social status and vocation of the patient are of great impor- 
tance in deciding for or against operation. A patient so situated that 
he may take every possible care of himself need not decide upon an 
operation as rapidly as one who must work hard for a living. 

Hence, the following indications for operative interference in 
chronic appendicitis may be laid down : 

1. If, after an acute attack of appendicitis, severe and other 
disturbances (pain, sensitiveness, etc.) persist, operation is to be 
performed as soon as possible in those whose vocation necessitates 
work. In other cases operation is indicated only after other reme- 
dies have failed. 

2. In relapsing appendicitis, especially among the working classes, 
operative interference is indicated when the attacks occur at short 
intervals and become more and more severe. If the interval 
between the primary and the next succeeding attack is more than 
three years, operation may be delayed or advised against. 

Borchardt gives two further indications which, for the purpose 
of completeness, we here repeat : 

(a) In women, operation is indicated when the adnexa are 
affected by the inflammatory process. Early operation may pre- 
vent infection of the adnexa of the left side. 

(b) Operation is indicated when, as a consequence of adhesions 
between the appendix and the female adnexa, severe symptoms occur 
during pregnancy, which tend to produce abortion or miscarriage. 

Finally a few remarks on the operative treatment of tubercular 
appendicitis are in place. We have previously stated that, accord- 
ing to literature, this class of cases concerns individuals with a 
tubercular constitution in whom the appendicitis is only a compli- 



504 DISEASES OF THE INTESTINES 

cation. In ray opinion, operation in these instances is as little indi- 
cated as in a tubercular kidney with marked pulmonary phthisis. 
The few cases which were operated i Korte and Sonnenburg) died 
in a short time. Borchardt reports two cases of tuberculosis of the 
caecum with fistulas in the ileo-caecal region. Both patients died 
soon after operation. 

The prognosis after operative treatment of actinomycotic appen- 
dicitis is also unfavourable. Of the twelve cases reported in Son- 
nenburg's monograph (to which we add another case recently 
reported by Karewski ffl ) only one was cured. 

In conclusion, a few remarks on the relation between the physi- 
cian and the surgeon appears to me appropriate. VTe consider it 
very desirable that, wherever possible, in every case of apparently 
severe appendicitis a surgeon shall be immediately consulted. It is 
not necessary to operate at once, but the case is to be observed 
and studied by both practitioners, and the proper time for surgical 
interference watched for. In public hospitals this is readily accom- 
plished, but in private practice it should be followed to a greater 
extent. The surgeon who in a given case decides for conservative 
measures instead of for operation, will not lose, but gain, in repu- 
tation. 

[The preceding chapter describes very fully the modern conti- 
nental view of appendicitis, particularly from the standpoint of the 
general practitioner. Wnetker from climatic, racial, dietetic, or 
other influences, the type of the disease in Europe is a far milder 
one than in the United States, or whether, because less prevalent, 
its gravity is not so fully appreciated, certain it is that the medical 
profession abroad regard appendicitis in a far more sanguine light 
than we do in this country. It appears therefore in place to sum- 
marize the American ideas of appendicitis as gathered from litera- 
ture and personal experience. 

^Vithin recent times no other affection has been the subject of 
so much discussion, demonstration, study, and writing. In this 
country, appendicitis is of such frequency that almost every layman 
is acquainted with its manifestations and dangers. Fitz's 91 masterly 
monograph taught us the proper significance of, and gave the impetus 
to, the further study of ileo-eaecal inflammations. The brilliant 
operative results of Morton* 4 , Sands 92 , McBurney 93 , ^Veir 94 , and 
others demonstrated practically what Fitz theoretically taught, 
viz., the possibilities of surgery in this domain. .Rapidly experi- 



TYPHLITIS. PERITYPHLITIS (APPENDICITIS) 



505 



ences multiplied, definition in diagnosis, prognosis, and treatment 
became more exact, and to-day the clinical phases of the disease are 
far better understood. ^Ve have come to regard appendicitis essen- 
tially as a surgical condition, and one which must therefore be 
treated upon strictly surgical principles. It is everywhere recog- 
nised by general practitioners that each case of appendicitis ought 
i at least in large cities) to be treated by, or in conjunction with, a 
competent surgeon.* This fact is also understood by our general 
public ; and once the diagnosis is made or suspected, the possibility 
of an immediate or future operation is entertained. In all our 
hospitals patients with appendicitis are assigned to the surgical 
di vision. + 

The terms typhlitis, caecitis. iliac abscess, pericecal abscess, and 
perityphlitis, though still mentioned in text-books and monographs 
have been completely dropped in practice. That primary inflam- 
matory (suppurative) conditions of the caecum may occur is not 
denied, but if they do occur they must be exceedingly rare, and 
clinically indistinguishable from appendicular processes : J there- 
fore no practical value attaches to their separate consideration. 
Clinically, at least, the diagnosis " appendicular (vermicular ) colic " 
is never made in this country, for that condition is regarded as 
identical with a mild form of catarrhal appendicitis (Hartley", 
Fowler- . 

For the reasons stated at length in the main body of the present 
chapter, and which, together with a few additional facts, shall now 
be briefly recapitulated, appendicitis differs essentially from other 
inflammatory and ulcerative processes of the intestines. 

The vermiform appendix in man, being in an evolutionary state, 
has a natural tendency toward obliteration ; hence it can offer but 
a feeble resistance to deleterious influences. Owing to its verv rich 



* [•• It must be confessed that, according to our present views, appendicitis is a 
surgical rather than a medical affection, particularly from the standpoint of treat- 
ment " (Anders 95 ).J 

[•' The disease is. properly speaking, a surgical one " (Lockwood 96 ).] 

[" In the majority of instances appendicitis is a surgical affection." writes 
Pepper 97 , one of the strongest advocates of the opium treatment.] 

f [Osier 9S remarks : " So impressed am I by the fact that we physicians lose lives 
bv temporizing with certain cases of appendicitis, that I prefer, in hospital work, 
to have the suspected cases admitted directly to the surgical side.*'] 

\ [According to McBurney, 99 per cent of all typhlitic abscesses are of appen- 
dicular origin.] 

# [Loc. cit., p. 45.] 



506 DISEASES OF THE INTESTINES 

lymphatic structure, excessive secretion readily results from irrita- 
tion. The disproportion between the length and the diameter of 
its lumen, the scarcity of contractile muscle fibres, the presence of 
faecal concretions and of G-erlach's valve, and of other physiological 
strictures, and the pendent position of the organ, favour the stag- 
nation of this excessive secretion. As a result, there is increased 
pressure within the appendix. Concretions and other foreign 
bodies produce erosions and ulcerations of the wall. The nutrient 
vessels being terminal branches, there is no provision for the estab- 
lishment of compensatory anastomosis, the circulation is readily 
embarrassed, and, unless the stagnation within the lumen is relieved, 
gangrene results. The presence of bacteria adds an infectious ele- 
ment to the process, and may lead to the formation of an abscess 
within the appendix (empyema), or (with or without perforation) to 
suppurative processes in the surrounding parts. General sepsis 
may also occur. 

Usually the changes involve the entire appendix. Hartley 77 
states that some appendices which he had removed in the first 
twenty-four to forty-eight or even seventy-two hours of the dis- 
ease, showed changes only in the mucosa and submucosa. If the 
serous coat becomes affected, a local peritonitis, with the formation 
of more or less extensive adhesions, results. " These adhesions may 
repeatedly form an efficient protective wall, but often they are 
powerless to prevent the further spread of a purulent peritonitis. 
This is the most important phase of the pathology of appendicitis, 
and is a condition which we will never be able to overcome" 
(Stein 99 ). The existence of such a condition is a strong argument 
against waiting for an abscess to become absorbed, or against delay- 
ing the operation until firm adhesions have formed. In very acute 
cases the infective process may spread so rapidly that there is 
no time for adhesions to form, and an acute general peritonitis 
supervenes. 

In addition to empyema, ulceration, and perforation, the appen- 
dix may be the seat of other pathological changes, particularly 
where there have been repeated attacks. Strictures and cystic con- 
ditions may develop, the lumen may be obliterated, or the wall of 
the appendix become thickened and indurated. Sometimes the 
entire appendix is embedded in a mass of adhesions, and loses its 
original appearance and character. 

'No new facts relative to the conservative treatment can be added 
to those described on page 458. It is well, perhaps, to briefly 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 507 

define the position assumed in this country in regard to opium and 
cathartics. 

As in other countries, views differ regarding the propriety of 
prescribing opium and its alkaloids in appendicitis. In private 
practice there is a constantly increasing tendency to limit their 
employment. Surgeons, as a rule, condemn their administration, 
at least until the diagnosis has been made or operation decided upon. 
Even then opium should be used in minimum amounts, just sufficient 
to relieve pain. It has been stated that a pain unrelieved by an 
ice bag, etc., and severe enough to require large doses of opium, 
constitutes in itself a sufficient indication for operation (Wiener 100 ). 
The objections to opium are : (a) That it masks the symptoms and 
produces a false euphoria, rendering it impossible to properly esti- 
mate the attack ; (b) that it favours the development of a tympani- 
tis which we may be unable to differentiate from that of a begin- 
ning peritonitis (Wiener) ; and (c) that in large doses it is apt to 
induce an intestinal paralysis. The points in favour of its use have 
already been mentioned (page 458). Pepper 97 considers opium in 
full doses as " the great standby," and that it has greatly lessened 
the mortality from appendicitis. Einhorn 101 considers opium the 
remedy par excellence. Deaver 102 permits its use for the relief of 
pain, but only after a purgative action has been obtained ; he con- 
siders the local use of ice much better than the administration of 
opium. Lockwood 96 also would give opium, but not to the extent 
of semi-narcotism. 

The use of cathartics is still a disputed question. Recently 
salines were extensively employed and recommended by surgeons. 
Deaver m claims never to have seen any harm from catharsis. He 
certainly does not voice the general opinion when he says : " Pur- 
gatives are capable of doing much more good under these circum- 
stances than any other class of drugs. ... I am positive, after con- 
siderable experience, that the good from purging will overbalance 
by far the harm done by active peristalsis. The writers who oppose 
the use of these drugs are evidently limited in their experience 
with the disease, otherwise they would not so believe." Tiffany 103 
also favours free purging. In general, both medical and surgical 
authorities condemn their use during an acute attack (Osier 98 , Mc- 
Burney 85 , Einhorn 101 , McNutt 1W , Mynter 89 , Pepper 9T , etc.). Tyson 105 
opposes their employment in advanced cases, but thinks their early 
administration in mild or moderate cases may clear up the diagnosis, 
or, by depletion of the circulation, diminish the danger of peritonitis. 



508 DISEASES OP THE INTESTINES 

Against the use of cathartics it is urged that they are not needed, 
since the caecum is rarely filled with faecal accumulations ; that cathar- 
tics tend to increase nausea and general unrest ; and that by exciting 
peristalsis they prevent the formation of fresh adhesions, and break up 
those already formed, but not yet firm. Finally, it must not be lost 
sight of that, even in the very earliest stages of appendicitis, we can 
never tell how near the appendix is to perforation. Hence, in gen- 
eral, it is best to defer the administration of purgatives until after 
operation, or until the attack has passed off. If it be necessary to 
empty the lower bowel earlier, an enema will answer very well. 

What are the recognised indications for operation ? In endeav- • 
ouring to answer this question the writer has consulted the publica- 
tions of recognised American authorities,* and has also drawn upon 
personal experience in hospital and private practice. He finds that 
there has been a considerable change of opinion since the clinical 
and pathological manifestations of appendicitis have received more 
direct attention. In the earlier days it was universally recom- 
mended to wait until an abscess had formed. The discovery and 
publication of McBurney's point 106 was a most decided advance in 
the early diagnosis of acute appendicitis. Taught by sad ex- 
periences, the American profession has come to appreciate the 
dangers which attend postponement of operation, and, emboldened 
by the success of modern surgical methods, has learned to be more 
radical in its treatment of appendicitis. 

We recognise that owing to anatomical peculiarities, an appen- 
dix once the seat of a more than very slight inflammation will never 
return to its normal state, and that this predisposes the organ to 
fresh attacks. We believe that with each fresh attack the patho- 
logical state of the appendix is aggravated. There are no specific 
internal remedies for the cure of appendicitis. Treated conserva- 
tively, mild cases often recover with a restitutio ad integrum, or 
with no further changes than strictures of the lumen ; severer 
cases may be attended by any of the processes already mentioned. 
Exceptionally, an extra appendicular abscess ruptures externally or 
into a hollow abdominal viscus (bladder, caecum, rectum, etc.), and 
relief or spontaneous cure follows.f 

The abscess has occasionally perforated the diaphragm and dis- 

* [See Literature at the end of this chapter.] 

f [Lloyd 107 reports a very interesting and instructive instance of acute appen- 
dicitis occurring in a man in whom years before a peri-appendicular abscess had 
ruptured and discharged into the rectum.] 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 509 

charged through the lung. The danger and inconvenience of such 
conditions are too apparent to call for any comment. 

In the vast majority of cases we are unable, without laparotomy, 
to determine the condition in the ileo-csecal region. "We cannot 
tell how near the appendix is to perforation ; whether there are any 
adhesions, and, if so, how firm ; whether there will be any further 
attacks, etc. To guide us in our disposal of a case, we must appeal 
to our experience and the results of pathological research. 

With but few exceptions the profession have therefore come to 
regard appendicitis as a surgical affection. This applies as well to 
the simple catarrhal as to the suppurative and other severer forms. 
If, then, during a slight or moderately severe acute attack we resort to 
rest in the recumbent position, an ice bag, restricted diet, and other 
conservative measures, in the endeavour to tide the patient over the 
attack, we are none the less fully alive to the possibility of an im- 
mediate or the probability (almost certainty) of a future operation. 
We watch our cases very carefully, and are prepared for immediate 
surgical interference should indication arise. Experience has taught 
that the period of quiescence between attacks offers the best 
chances for operative success. The patient or his friends are in- 
structed concerning the gravity of the situation, and such details are 
explained to them as are necessary for their clearer judgment. For 
with the family, after all, will rest the consent to operate. 

Contraindications to Operation. — Besides the withholding of 
the consent of the patient or those responsible for him, operation 
may be impossible or inadvisable for other reasons. Such would 
be inadequate surroundings, failure to obtain proper assistance, sur- 
gical inexperience of the medical attendant, too far advanced con- 
dition of the case (sepsis, extreme weakness, moribund state, etc.) 
coincidence of other serious disease, etc. 

In the absence of these adverse circumstances the following are 
the generally accepted indications for operation : * 

I. Interval operation. f 

(a) In mild cases after two or more attacks. 

* [The following indications apply only to patients residing in large cities or 
otherwise accessible to immediate surgical interference. For those who travel 
much, who live in the country, or who must perform severe physical labour, etc., it 
is best to remove the appendix during or after a first attack.] 

f [It is best to wait about two to four weeks after even mild attacks, until the 
inflammation has become quiescent. The mortality under such circumstances, 
even in difficult and unfavourable cases, is, in the hands of a good operator, 1 per 
cent or 2 per cent (McBurney).] 



510 DISEASES OF THE INTESTINES 

Willy Meyer 108 * advises the radical operation after recovery 
from any attack of appendicitis, mild or severe. Deaver 83 , Myn- 
ter 89 , and a few other surgeons, favour immediate operation in all 
cases of appendicitis as soon as the diagnosis is made. 

(b) After recovery from an attack of ordinary or more than 
ordinary severity. 

Here general practitioners and surgeons are almost unanimously 
agreed that it would be assuming too great a risk to expose the 
patient to the dangers of a repeated attack. 

II. Immediate operation. 

1. In cases of ordinary severity with sharply defined symptoms. 

(a) Whenever there is a tumour present in the ileo-csecal region. 

(b) Whenever there is sudden or progressive increase in the 
gravity of the symptoms. 

(c) When, after thirty-six to forty-eight hours, the case does 
not show any tendency toward improvement, but the condition 
remains stationary. f 

(d) Whenever there is any donbt as to the existing condition 
and the patient's improvement most authorities advise immediate 
operation. In this instance timely operation is better than the un- 
certainty and dangers which attend delay 4 

2. In all the severer forms of appendicitis — i. e., those in which 
the symptoms point to pns in or about the appendix (with or with- 
out peritonitis), to perforation, or to severe systemic infection — we 
cannot operate too early. It is wrong to delay and attempt to 
determine the pathological conditions present, for we will rarely 
arrive at more than a probable diagnosis, and every delay may cost 
the patient his life. In all cases of acute appendicitis the earlier 
the operation the easier its performance, the better the condition of 
the patient, and the more certain are the chances of success. — Tk.] 

* [Willy Meyer reminds us that the first attack is really not the first pathologi- 
cal symptom, but rather the " first explosion."] 

f [Here one must be guided, in advising immediate or interval operation, by 
the existing circumstances, particularly by the general condition of the patient and 
the care with which the case can be watched.] 

X [McBurney 85 , one of our greatest authorities on appendicitis, says, in referring 
to this indication for operation : " No greater mistake can be made than to wait 
for very clearly defined signs of advanced and grave disease before deciding to 
operate. Operation, to be usually successful, must be done before grave disease is 
well pronounced."] 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 511 

APPENDIX 
Sigmoiditis and Pericolitis 

(a) Acute Sigmoiditis 

Under this name A. Mayor 69 has described a condition which 
consists in an inflammation of the sigmoid flexure and occasionally 
of the neighbouring peritoneum and cellular tissue ("iliac phleg- 
mon"). Mayor believes that this affection is caused by faecal 
impaction in the sigmoid or by irregular defecation. Both causes 
may, however, be absent. Fever may or may not be present. The 
region of the sigmoid is always indurated, swollen, and sensitive to 
pressure ; suppuration and rupture into the intestine may occur. 
All the cases were marked by rapid convalescence. Mayor leaves 
it undecided whether the disease is produced by purely mechanical 
factors or by specific infection (e. g., erosions). 

To illustrate the clinical picture, it seems best to present a brief 
analysis of the clinical histories reported by Mayor : 

Case I. — A woman, thirty-two years old, who, excepting for constipation, 
had always been well. On examination of the region of the sigmoid flexure, 
there was felt a cylindrical swelling which was continuous with the descend- 
ing colon above, and disappeared toward the pelvis. Rectal examination 
showed nothing abnormal. This condition developed without fever, and 
disappeared under the use of cataplasms. 

Case n. — Boy, fourteen years old, became ill with fever, pain in the left 
side, and local symptoms similar to the above ; after fever for several days the 
boy recovered. 

Case III. — Boy, eleven years old, became ill with high fever; suppuration 
occurred, and the abscess ruptured into the intestine. 

Case IV. — Physician, forty-two years old, sudden, severe, paroxysmal 
pains in the sigmoid region, accompanied by nausea ; no constipation, no fever. 
The sigmoid flexure was indurated, swollen, and sensitive. Recovery after a 
few days. 

In a case recently reported by Galliard, 70 there were severe general symp- 
toms, with fever, and pain in the left iliac fossa. There was a tumour the size 
of an orange, which disappeared after three weeks. 

In the absence of autopsies, certainty regarding the pathogenesis 
of the disease is scarcely possible. It seems very difficult to differ- 
entiate acute sigmoiditis from inflammation of the caecum, or an 
appendix displaced to the left. Chronic enteritis with acute exacer- 
bations may also be mistaken for sigmoiditis, especially since fever 
is not a necessary symptom of the latter. Finally, inflammation of 
the left female adnexa may also require diagnostic consideration. 



512 DISEASES OF THE INTESTINES 

Mayor deserves credit for having pointed out that inflammatory 
processes may occur in the left iliac fossa. Further study of these 
conditions, and the knowledge derived from operative procedures, 
will be required before we can say that there is proper justification 
for considering this affection as an inflammation of the sigmoid 
flexure. 

The same treatment must be applied as in typhlitis : rest in bed, 
ice, or, when this is not well borne, warm applications, regulation of 
the bowels, and opium (internally, subcutaneously, or in supposi- 
tories) when the pain is severe. 

(o) Chronic Sigmoiditis 

By chronic sigmoiditis I mean an affection in which there is 
constant pain and sensitiveness to pressure in the region of the 
sigmoid flexure. Further symptoms are severe diarrhoea, accom- 
panied by more or less mucus, or by attacks of constipation. 

Yon Leube 71 and Rosenheim 72 also report chronic inflammatory 
infiltration of the sigmoid flexure with a " smooth, regular, increased 
resistance." Since chronic sigmoiditis is but little known, I will 
briefly report two cases from my journal : 

Case I. — Mrs. F. R., of Berlin, age thirty-nine. No hereditary disease ; 
has had four severe labours and two abortions, produced, she says, by falling and 
jolting. Her present symptoms have lasted eleven years, and are ascribed by 
her to the first confinement, which was an instrumental delivery with complete 
tear of the perinseum. A recto-vaginal fistula remained, and caused the patient 
much annoyance. Three years later the fistula was operated on by Prof. 
Fritsch. Patient felt better for a few months after the operation, but the symp- 
toms gradually returned, and at present they are at their greatest intensity. 
They consist of pains in left lower abdominal quadrant, flatus, and morning 
diarrhoea (two to four movements) with much mucus. Blood has never been 
found in the stools. Frequent tenesmus, which only ceases after injections of 
chamomile infusion. The diarrhoea alternates with normal stools for one to two 
days. On such days the patient feels much better. The other gastro-intestinal 
functions are absolutely normal. All treatment (oil enemata, opium, tannalbin r 
etc.) has been without effect up to the present time. 

Status Prcesens. — Pale, well-nourished woman. Organs of respiration and 
circulation normal. 

Abdomen. — Many striae, abdominal panniculus flabby (pendulous abdomen), 
splashing and succussion sounds in the gastric region. Lower border of the 
stomach (carbonic-acid inflation) reaches to the umbilicus. 

The slightest palpation in the region of the sigmoid is extremely painful. 
As the examining finger passes upward the sensitiveness becomes less, and at 
the splenic flexure disappears entirely. No resistance to be felt. Rectal exam- 
ination negative. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 513 

Urine. — Normal; no indicanuria. 

Stools. — Two to three stools daily, of semisolid consistency, and mixed 
with viscid mucus. Microscopically nothing of importance, particularly no 
blood, pus, or amoebae. 

Stomach. — Motility normal, marked hyperacidity (0.28 per cent HC1). 

During the clinical examination there were six to seven thin stools, accom- 
panied by severe tenesmus. The treatment consisted in absolute rest in bed, 
astringent diet, hot poultices over the sigmoid flexure, and rectal irrigations 
with bismuth mixtures (bismuth, \ ounce ; water, 1 litre). 

After four weeks of treatment patient showed considerable improvement ; 
had one to two well-formed stools daily; painless defecation, and much dimin- 
ished sensitiveness over sigmoid. 

Case II. — Mr. S., of W., thirty-two years old. In February, 1896, while in 
India, he had a severe attack of acute dysentery, which slowly improved after 
about four weeks. A sensitive area remained, however, in the left lower 
portion of the abdomen. Pain was particularly evident while riding, so as to 
necessitate the giving up of that exercise. After walking about for several 
hours the patient usually felt more or less severe pain in the above-mentioned 
area. Appetite good. Stools always show a tendency to diarrhoea. Examina- 
tion reveals circumscribed sensitiveness and a feeling of light resistance over 
the sigmoid flexure. Everything else normal. 

These cases demonstrate that local inflammation of the sigmoid 
does occur. In the first instance the etiology was very probably 
an infection originating in the recto -vaginal fistula ; the second case 
very probably originated from the previous dysentery. 

The diagnosis is made from the catarrh of the large bowel, and 
from the sharply defined sensitive area corresponding to the sigmoid 
flexure. There need not be a demonstrable resistance. Differen- 
tially, we must, in the first place, consider malignant neoplasms, and 
then diseases of the female adnexa. By careful examination we 
ought to be able to exclude both groups of diseases. 

The treatment is the same as that of chronic catarrh of the large 
intestine. 

(c) Exudative Pericolitis ; Primary Submucous, Circumscribed 

Colitis {Pal) 

Under the name of exudative pericolitis, "Windscheid 73 , of the 
Leipsic Clinic, first described a condition characterized by the de- 
velopment of acute exudative peritonitis about the ascending colon. 
This affection is distinguished from typhlitis and appendicitis in 
that the right iliac fossa is entirely free, and from tumour by the 
acute onset and constant fever. In the same year Eisenlohr 74 re- 
ported " a case of abscess behind the ascending colon." Since this 



514 DISEASES OF THE INTESTINES 

is the only instance in which an autopsy was performed, its impor- 
tant points are here briefly recapitulated. 

A ferryman, thirty-one years old, alcoholic, with cirrhosis of the liver, on 
March 31st became ill with chills, vomiting, diarrhoea, and marked abdominal 
distention. On examination, the right hypochondrium was found sensitive to 
pressure, and painful ; pulse frequent ; diarrhoea ; vomiting bilious but not 
feculent ; urine contains no albumin ; peptonuria found once. 

March 24th. Fluctuation in the abdomen with disappearance of perito- 
nitis ; later, ascites ; evening temperature 39° 0. 

Death on May 29th. Autopsy showed a small abscess cavity situated be- 
low the upper portion of the ascending colon and between the hepatico-colic 
ligament, the anterior surface of the kidney capsule, and the descending j3or- 
tion of the duodenum. This cavity contained a scanty amount of semisolid, 
inspissated, yellowish pus. The mass measured about ten centimetres verti- 
cally, and somewhat less horizontally. Its position corresponded to the mesen- 
tery of the upper portion of the ascending colon. The walls of the abscess 
cavity were tough, and thickened by connective tissue ; the peritoneum of the 
intestines, particularly that of the caecum and appendix, showed no trace of 
previous inflammation. The entire mucous membrane presented no evidence 
of previous ulcers, cicatrizations, or infiltrations. The abscess was entirely 
outside of the intestinal wall. 

In 1895 Fleiner 75 reported a case which he also described as a 
pericolitic exudate. J. Pal 76 recently published a series of such 
observations, in which he thoroughly discusses the question. Pal's 
cases include exudates about various portions of the large intestine, 
five cases of ascending colitis, one of colitis of the left or both flex- 
ures, one of colitis of the right flexure, and one of descending 
colitis. He considers colitis as a submucous infiltration which is 
developed from peculiar changes in the intestinal contents, and 
which either suppurates and ruptures or is absorbed. 

I also am in a position to report a case of this kind which, after 
laparotomy, came to the autopsy table. 

H. K., nineteen years old, student. As a child suffered from pertussis 
and frequent pulmonary and intestinal catarrhs. In 1889 tubercular knee and 
hip-joint disease, cured by extension and iodoform injections. After the 
chloroform narcosis then necessary, for the first time there developed vomiting, 
with colicky pains and marked sensitiveness in the left side of the abdomen. 
Cure after eight days. Then absolutely well for six years. On March 22d, 
1897, another attack after drinking cold beer. Severe pain in the umbilical 
region, marked vomiting, and constipation. These attacks were repeated five 
times in four weeks, each time lasting one to three days. The last attack be- 
gan April 20, 1897, with severe colicky pains to the left of the umbilicus, and 
radiating to the back. Vomiting and constipation ; no fever (?). When seen 
in consultation (April 23d), to the left of the umbilicus there was felt an in- 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 515 

tensely painful, incompressible resistance the size of an apple. Since the 
attendant physician has given the patient laxatives and irrigations, fascal 
tumour can be absolutely excluded. Neoplasms also, because of the intense 
sensitiveness. The diagnosis of serous exudative pericolitis was therefore 
made. 

Treatment. — Rest in bed, ice bag, opium per rectum, fluid diet. First 
stool four days after these regulations. Resistance can still be felt. Four 
days later, tumour can no longer be felt. May 5, 1897, tumour had entirely 
disappeared ; no sensitiveness in the area above mentioned. General condition 
good. Course of waters at Kissingen in the summer of 1897 followed by 
favourable results. In autumn, 1898, new attacks at intervals of three to four 
weeks ; at the last attack (end of October) there was absolute retention of 
stool and flatus. On October 31st, laparotomy performed by Professor Riedel, 
of Jena. The following facts are borrowed from his report of the case : 

Incision shows the transverse colon moderately distended by gas ; isolated 
white patches in the mesentery. To the left and above the cicatrized omentum 
is adherent to the tip of the spleen, which is very movable. The splenic flexure 
is extremely coiled, the individual coils being connected to one another by 
glistening, white, cicatricial tissue. Loosening of the mesenteric adhesions. 
Ether bronchitis ; death from diffuse peritonitis. 

In my opinion, these numerous scar tissue adhesions were the 
remnants of many previous attacks of exudative peritonitis. 

Despite the small number of cases which have been observed, 
there is no doubt that, clinically, there do occur serous or purulent 
exudates without involvement of the appendix. Their etiology is 
difficult to determine. The explanation given by Pal is founded 
upon a case of Eisenlohr's, but since the entrance point for the de- 
velopment of the abscess is unknown, this case must be used only 
with the greatest caution for the establishment of a new disease. 

Symptomatology and Diagnosis 

According to Pal's description, the onset is sudden, with symp- 
toms of inflammatory swelling of the large intestine, accompanied 
by fever, nausea, or vomiting ; there soon develops a sensitive area, 
painful to pressure, and, in a few days, a palpable resistance. The 
resistance may rapidly increase in extent ; at this stage the tumour 
is quite sensitive to pressure. When fever subsides the sensitiveness 
also disappears. The rest of the abdomen is slightly or not at all 
affected by the process. 

The most frequent site of the disease is the hepatic, less fre- 
quently the splenic flexure. The process may develop in other seg- 
ments of the large intestine, particularly in the ascending colon. 
"When affecting the descending colon or the sigmoid flexure, the 



516 DISEASES OF THE INTESTINES 

clinical picture is the same as that of sigmoiditis (Major). Occa- 
sionally, several intestinal segments may be simultaneously in- 
volved. In the beginning the clinical picture may impress one as 
that of a circumscribed peritonitis, but the rapidly developing cylin- 
drical area of resistance points directly to the intestines as the origin 
of the lesion. 

The fever is generally of short duration and may be overlooked, 
but when suppuration supervenes it may become quite marked. In 
the beginning the bowels may be normal or constipated. Fre- 
quently there is an accumulation of gas. There is often marked in- 
dicanuria. 

Differential Diagnosis 

Differentiation from typhlitis and perityphlitis is the first con- 
sideration, particularly when the process is localized on the right 
side in the neighbourhood of the caecum. Pal places a certain value 
on palpation and percussion for the separation of the caecum from 
the diseased colon. He, however, seems to undervalue the dif- 
ficulties of an exact differential diagnosis of this disease from peri- 
typhlitis. When we consider the numerous variations in position 
of the caecum, and the different localities of peri ty phi itic abscesses 
and exudates, error would appear unavoidable. When the colitis is 
situated in the vicinity of the right hypochondrium, cholelithiasis 
may have to be considered, and, under complicating conditions, the 
diagnosis may be very difficult. Perigastritis and perinephritis 
may also come into question. 

Treatment 

In general the treatment embodies the usual principles employed 
in all inflammatory processes of the intestine — rest in bed, ice, in- 
testinal irrigations, and opiates when the pain is very severe. Dur- 
ing the first few days fever diet should be given ; in the following 
days the diet is that of appendicitis after the acute inflammatory 
symptoms have disappeared (see page 154). After the exudate has 
fully developed and acute symptoms have diminished, warm appli- 
cations are in place. Pal particularly recommends hot flaxseed 
poultices. We may later attempt to aid absorption of the remain- 
der of the exudate by massage, and iodin and mercurial oint- 
ments. When a fluctuating abscess develops, incision should not 
be delayed. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 517 

Repeated attacks of pericolitis or signs of chronic adhesive, in- 
testinal inflammation may require surgical treatment, but at present 
the success of such operations is doubtful. 



LITERATURE 

1. Sahli. Verhandl. des XIII. Congresses f. innere Medicin, Wiesbaden, 1895. 

2. Harley. St. Thomas Hosp. Rep., vol. xi, p. 128, 1881. 

3. Manage. Contribution a l'etude de l'intervention chirurgicale dans les in- 

flammations pericoecales, These de Paris, 1891. 

4. Curschmann. Verhandl. des XIII. Congresses f. innere Medicin, Wies- 

baden, 1895, S. 291. 

5. Lennander. Ueber Appendicitis, Wien u. Leipzig, 1895. (Cases 70 and 

71); cf. also Volkmann's Samml. klin. Yortrage, 1893, No. 175. 

6. Porter. Medical News, p. 209, 1895. 

7. Kronlein. Vereinigung Schweizer Aertzte, 1893. 

8. Manley. Cited by Borchardt, Grenzgebiete, 1897, Bd. ii, S. 310. 

9. Meusser. Ibid., Bd. ii, H. 3 u. 4. 

10. Borchardt. Ibid., Bd. ii, S. 312. 

11. Ribbert. Virchow's Archiv, Bd. cxxxii, 1893. 

12. Maurin. These de Paris, 1890. 

13. Bryant. Cited by Fowler, Ueber Appendicitis, Berlin, 1896. 

14. F. von Sydow. Cited by Lennander, Ueber Appendicitis, p. 17. (See 

ref. 5.) 

15. Krausshold. Yolkmann's Samml. klin. Yortrage, No. 191, 1881. 

16. Renvers. Deutsche med. Wochenschr., 1891, S. 177. 

17. Treves. Perityphlitis and its Varieties, London, 1897, p. 9. 

18. Murphy. Cited by Treves, loc. cit. 

19. Tavel u. Lanz. Ueber die Aetiologie der Peritonitis, Basel, 1893. 

20. Eckehorn. Upsala Lackareforen, Foerhandlingar, 1893. 

21. Morris. Centralblatt fur Chirurgie, 1895, S. 609. 

22. Karewski. Deutsche med. Wochenschr., 1897, Nos. 19-21. 

23. Nothnagel. Darmkrankungen. S. 639. 

24. Steiner. Zur pathologischen Anatomie des Wurmfortsatzes, Basel, 1892. 

25. Zuckerkandl. Ueber die Obliteration des Wurmfortzsatzes beim Menschen, 

Wiesbaden, 1894. 

26. Talamon. Medecine moderne, 1896, No. 9. 

27. Coley. New York Med. Rec, Feb. 15, 1896. 

28. Small. Ibid., Sept. 10, 1898. 

29. Golubeff. Berl. klin. Wochenschr., 1897, No. 1. 

30. Penzoldt. Penzoldt-Stintzing's Handbuch, Bd. iv, S. 666. 

31. Sonnenburg. Pathologie u. Therapie d. Perityphlitis, 2te Auflage, Leip- 

zig, 1897. 

32. Rotter. Ueber Perityphlitis, Berlin, 1897. 

33. Kummell. Ueber Perityphlitis, Leipzig, 1896. 

34. Fowler. Ueber Appendicitis, Berlin, 1896, S. 68. [A Treatise on Appen- 

dicitis, Philadelphia, 1901.] 
34 



518 DISEASES OF THE INTESTINES 

35. Edebohls. Amer. Journal of the Med. Sciences, May, 1894. 

36. Richardson. Ibid., January, 1894. 

37. Naumann. Hygeia, 1891. 

38. Mannaberg. Centralbl. f. innere Medicin, 1894, No. 10. 

39. von Hochstatter. Beitrage zur Chirurgie, Festschrift fur Billroth. Cited 

by Nothnagel, Darmkrankheiten. 

40. Caspersohn. Munch, med. Wochenschr., 1893, No. 43. 

41. Goldbach. Prager med. Wochenschr., 1898, No. 16. 

42. A. Pick. Yorlesungen liber Magen- u. Darmkrankheiten, Leipzig u. Wien, 

1897, S. 58. 

43. Monod et Vanvers. L'Appendicite, p. 83. 

44. Bull. New York Med. Rec, 1894, vol. ii, p. 30. 

45. Naunyn. Klinik der Cholelithiasis, Leipzig, 1892, S. 86. 

46. Curschmann. Deutsches Arch, fur klin. Medicin, Bd. liii, H. 1 u. 2. 

47. Sonnenburg. Deutsche med. Wochenschr., 1897, No. 40. 

48. Sheild. Internat. Magazine, January, 1895. 

49. Heubner. Congress f. innere Medicin, Miinchen, 1895. 

50. Rendu. Gaz. des Hopitaux, 1897, No. 40. 

51. Nothnagel. Wiener klin. Wochenschr., 1899, No. 15. 

52. Ewald. XXVIII. Congress d. deutschen Gesellsch. f. Chirurgie, 1899; 

Berl. klin. Wochenschr., 1899, No. 24. 

53. A. Fraenkel. Deutsche med. Wochenschr., 1891, No. 4. 

54. Wollberecht. Inaug.-Diss., Berlin, 1891 ; Conrad, Inaug.-Diss., Berlin,. 

1898 ; Croizet, These de Lyon, 1893. 

55. Gendron. These de Paris, 1885. 

56. Terrillon. Cited by Fowler (see ref. 34). 

57. Bull and Fowler. Cited by Sonnenburg (see ref. 31). 

58. Nothnagel. Darmkrankheiten, S. 699. 

59. E. Frankel. Volkmann's Samml. klin. Vortrage, 1898, No. 229. (Here 

will be found complete literature.) 

60. Ewald. von Leyden's Handb. der Ernahrungstherapie, 1898, Bd. ii, S. 266. 

61. Ferrand. Cited by Grohe, p. 100. 

62. Schede. Deutsche med. Wochenschr., 1892, S. 522. 

63. Mikulicz. Grenzgebiete, 1898, Bd. iii, H. 1, S. 163. 

64. Gerhardt. Ibid., Bd. i, H. 3, S. 354. 

65. Wieland. Mittheil. aus Kliniken u. medicin. Instituten d. Schweiz, 1895 r 

Bd. i, H. 7. 

66. P. Grawitz. Charite-Annalen, 1886, Bd. xi. 

67. Sonnenburg. Grenzgebiete, 1898, Bd. iii, p. 1. 

68. Kummell. Berl. klin. Wochenschr., 1898, No. 15. 

69. A. Mayor. Revue medic, de la Suisse Romande, 1893, No. 7, p. 421. 

70. Galliard. Traite de medecine (Brouardel-Gilbert), T. iv, p. 603, 1897. 

Gaz. des Hopitaux, 1897, No. 7. 

71. von Leube. Specielle Diagnose d. inneren Krankheiten, Leipzig, 1889, 

S. 281. 

72. Rosenheim. Pathologie u. Therapie d. Krankheiten des Darms, 1893 r 

S. 457. 

73. Windscheid. Deutsches Arch. f. klin. Medicin, 1889, Bd. xlv, S. 233. 



TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 519 

74. Eisenlohr. Deutsche med. Wochenschr., 1890, No. 44. 

75. Fleiner. Mtinch. med. Wochenschr., 1895, No. 42 et seq. 

76. J. Pal. Wiener klin. Wochenschr., 1897, No. 18 u. 19. 

[77. Hartley, F. Dennis's System of Surgery, Philadelphia, 1896, vol. iv, 

p. 385, etc.] 
[78. Kraft, C. Revue med. de la Suisse rom., Geneve, 1893, T. xiii, p. 764.] 
[79. McCosh and Hawkes. Amer. Jour, of the Med. Sciences, 1897, vol. ii, 

p. 885.] 
[80. Johnson, M. M. Jour, of the Amer. Med. Assoc, 1896, vol. xxvi, p. 

1202.] 
[81. Gerster, A. G. New York Med. Jour., 1890, vol. liii, pp. 6-14.] 
[82. Bayley, N. B. New York Med. Rec, 1895, vol. xlvii, p. 342.] 
[83. Deaver, J. B. A Treatise on Appendicitis, Philadelphia, 1900, p. 246, etc.] 
[84. Morton, T. G. Jour, of the Amer. Med. Assoc, 1888, p. 733.] 
[85. McBurney, Charles. Dennis's System of Surgery, Philadelphia, 1896, 

vol. iv, p. 415, etc] 
[86. Bull, W. T. Annals of Surgery, 1896, p. 764.] 
[87. Senn, N. Jour, of the Amer. Med. Assoc, March 6, 1896.] 
[88. Murphy, J. B. Medical News, January, 1895.] 
[89. Mynter, H. Appendicitis and its Surgical Treatment, Philadelphia, 1897, 

p. 143.] 
[90. Fenger, C. Amer. Jour, of Obstetr., 1893, vol. xxviii, No. 2.] 
[91. Fitz, R. H. Amer. Jour, of the Med. Sciences, 1886, pp. 321-346.] 
[92. Sands, H. B. New York Med. Jour., 1888, vol. xlvii, pp. 197-205 and 

607.] 
[93. McBurney, Charles. Ibid., 1888, vol. xlvii, p. 719.] 
[94. Weir, R. F. New York Med. Rec, 1889, vol. xxxv, p. 449.] 
[95. Anders, J. M. Text-Book of the Practice of Medicine, Philadelphia, 

1900, fourth edition, p. 812.] 
[96. Lockwood, G. R. Manual of the Practice of Medicine, Philadelphia, 

1896, p. 514.] 
[97. Pepper, W. American Text-Book of the Theory and Practice of Medi- 
cine, Philadelphia, 1894, vol. ii, p. 823.] 
[98. Osier, W. The Principles and Practice of Medicine, New York, 1898, 

third edition, p. 530.] 
[99. Stein, R. Erfahrungen liber Appendicitis. Deutsche med. Wochenschr., 

1899, No. 27, S. 442.] 
[100. Wiener, J. New York Med. Rec, May 19, 1900.] 
[101. Einhorn, M. Diseases of the Intestines, New Y'ork, 1900, p. 220.] 
[102. Deaver, J. B. Annals of Surgery, 1897, p. 325.] 
[103. Tiffany, L. McL. Reference Handbook of the Medical Sciences, 1900, 

vol. i, p. 428.] 
[104. McNutt, W. F. Amer. Syst. of Pract. Medicine, New York and Phila- 
delphia, 1898, vol. iii, p. 311.] 
[105. Tyson, J. The Practice of Medicine, Philadelphia, 1900, p. 404.] 
[106. McBurney, C. New York Med. Jour., 1889, pp. 676-684.] 
[107. Lloyd, S. New York Med. Rec, Feb. 10, 1900, p. 228.] 
[108, Meyer, W. Ibid., Feb. 29, 1896.] 



CHAPTER XXIII 

DISEASES OF THE RECTUM* 

1. Proctitis 

Proctitis is an inflammation of the mucous membrane of the 
rectum. It may be acute or chronic, circumscribed or diffuse, pri- 
mary or secondary. Its causes are but little understood. Undoubt- 
edly catarrh of the rectum may be caused by entozoa, particularly 
parasites of the large intestine (especially oxyuris vermicularis). 
The theory of an infectious proctitis in pruritus ani, hemorrhoids, 
foreign bodies, neoplasms, prolapsus ani, mechanical irritation, etc., 
is very plausible. The view constantly expressed, even in the most 
recent text-books and monographs, that there exists a connection 
between proctitis and the abuse of drastic purgatives, does not seem 
sufficiently proved. Among numerous observations, I have found 
but one instance of this kind. It is doubtful whether cooling of the 
pelvic region may produce proctitis. 

The most frequent cause of primary proctitis is best sought for in 
the composition and character of the evacuations themselves. These 
may both chemically and mechanically, and under certain circum- 
stances also bacteriologically, produce acute or chronic catarrh of 
the rectum. The most frequent causes of secondary proctitis are 
foreign bodies (fruit seeds, meat bones, fish bones, etc.), ulcerations, 
neoplasms, hemorrhoids (so-called mucous hemorrhoids), prolapsus 
ani, and rectal fistulas. Infectious diseases (gonorrhoea, diphtheria, 
dysentery) are also looked upon as etiological factors. 

As shown by recent investigations, gonorrhoea! proctitis may 
occur both in men and women. In men it results only from 
sodomy. In women it is very frequently due to the carrying over 

* The scope of this work only allows of a description of those rectal diseases 
which are particularly interesting to the medical practitioner. Malformations of 
the rectum, wounds, and foreign bodies will therefore not be discussed. Rectal 
cancer is found in the chapter on Intestinal Cancer (page 318) ; the neuroses of 
the rectum are found among the Intestinal Neuroses. 
520 



DISEASES OF THE RECTUM 521 

of gonorrhoeal secretions to the anal region, and, more rarely, to 
extension of inflammation from the Bartholinian glands, recto- 
vaginal fistulae, etc. Jullien 1 and Baer 2 have recently investigated 
the existence and nature of rectal gonorrhoea. The latter investi- 
gator found this disease in thirty-eight per cent of all women 
infected with gonorrhoea, though rarely with any subjective symp- 
toms. Gonococci are constantly found in these cases. Proctitis 
occurs frequently in women with extreme uterine displacements. 
Disease of the bladder and prostate may also produce proctitis. 
Buche 3 states that gout may also cause proctitis, but the connec- 
tion between these two diseases has not been proved. 

Symptomatology akd Diagnosis 

The symptoms of proctitis vary with the severity and extent of 
the process. In acute cases the inflammatory symptoms predomi- 
nate ; in the milder ones there is a feeling of fulness and pressure 
in the rectum. When the inflammation is severe the patients may 
complain of marked boring pain, accompanied by annoying tenes- 
mus. The pain may be limited to the rectum, or may radiate 
toward the back, external genitals, bladder, and lower extremities. 
The movements are generally voluntarily repressed, and every 
effort at evacuation produces spasm of the sphincter and levator 
ani. If, after continued tenesmus, the patient finally has an evacu- 
ation, the latter is always small and is scarcely ever purely fecu- 
lent, but is mainly bloody and muco-purulent. 

In the severest cases the general health is usually involved. 
The pain keeps the patients in bed, appetite and sleep are markedly 
diminished, and from the very beginning fever is generally present. 
The finger introduced into the rectum feels the contracted sphinc- 
ter, which allows further introduction only after very careful and 
gradual dilatation. The mucous membrane feels hot, oedematous, 
and swollen. Even when most carefully performed, digital explora- 
tion is very painful. On withdrawal, the finger is generally found 
smeared with blood or blood mixed with pus. 

In chronic proctitis the symptoms are much less characteristic. 
There is a feeling of straining and pressure, which in the presence 
of impacted faeces may amount to tenesmus. Digital examination 
is less annoying to the patient. The mucous membrane feels swol- 
len, soft, and velvety ; it bleeds easily, and occasionally secretes pus. 
Sometimes the swollen solitary follicles may be felt as prominences 
the size of millet seeds. Defecation may be painful. The stools 



522 DISEASES OF THE INTESTINES 

are often mixed with blood or bloody mucus ; in isolated cases (e. g., 
rectal gonorrhoea) they may consist entirely of pus. In acute as 
well as in chronic proctitis, a paralysis of the sphincter may result 
from the marked and deep infiltration of the inflammatory process, 
so that there is a continual discharge of bloody pus or muco-pus. 

Where the symptoms are well defined, the diagnosis of acute 
proctitis is usually easy and may generally be made without digital 
examination. For the diagnosis of the etiology digital exploration 
is necessary. It should be performed with the greatest caution- 
A very thin suppository of opium and cocain or eucain should be 
previously introduced. In place of this we may employ a collaps- 
able tin tube to which a short piece of rubber tubing is attached. 
The latter is well oiled and passed into the rectum. The collaps- 
able tube is then slowly squeezed and some of the ointment thus 
directly introduced into the rectum. The introduction of a specu- 
lum, especially without narcosis, is an unnecessary procedure. 
Fever, tenesmus, and bloody, mucoid, or purulent defecations with 
very little faecal matter are also of diagnostic importance. 

The diagnosis of chronic proctitis is best made by digital and 
speculum examination. Thus foreign bodies producing this affec- 
tion can scarcely escape discovery. Under certain circumstances 
the diagnosis of the nature of the process may be very difficult. 
If ulcerations are present, we must consider especially the tuber- 
cular, syphilitic, gonorrhoea^ and stercoral ulcers. These must be 
differentiated by clinical and, more particularly, by bacteriological 
examination (gonococci, tubercle bacilli). 

If no sufficient explanation for the occurrence of the disease is 
found in the rectum itself, the etiology must be sought for by 
examination of the remaining pelvic organs — in men, the bladder ; 
in women, the genitals. 

Teeatment 

Depending upon circumstances, the treatment of acute proctitis 
should be either symptomatic or radical. The latter plan is appli- 
cable when foreign bodies, inspissated faeces, diseases of the neigh- 
bouring organs, etc., are the cause of the proctitis. Symptomatic 
treatment must take into account those basic principles which 
apply to acute inflammations of the intestinal mucous membrane — 
above all, absolute rest and immobilization of the rectum. The 
abdominal or lateral posture is often recommended for the relief 
of the pain. If constipation is not the cause of the lesion, it is 



DISEASES OF THE RECTUM 523 

advisable during the acute inflammatory stage to keep the bowels 
constipated by opiates, given either per mouth or rectum. It is also 
necessary to decrease the amount and kind of the nourishment taken 
— an easy task in view of the diminished appetite of these patients. 
When the inflammatory symptoms have subsided the bowels may be 
moved by castor oil or by enemata of olive oil. After this expect- 
ant treatment has been applied for eight or ten days, the symptoms, 
in the vast majority of cases, disappear. In complicated cases the 
process extends, the suppuration spreads to the periproctitic tissues, 
and a periproctitis results (see below). 

Tenderness and tenesmus are generally well controlled by the 
above-mentioned narcotics. Leeches applied in the neighbourhood 
of the anus are also useful, and often curative ; their action is 
increased by warm sitz baths. 

Only after the acute symptoms have subsided should local treat- 
ment be begun, if at all. The utmost care must be exercised in the 
choice of our remedies. The most appropriate treatment is rectal 
irrigation with warm decoctions of chamomile or linseed, contain- 
ing a few drops of laudanum. Where there is copious purulent 
secretion, we may try irrigations with very dilute solutions of 
nitrate of silver (0.5 to 1 gram in 1,000) ; if these cause severe 
reaction, they should be followed by an irrigation with a weak salt 
solution. 

The management of chronic proctitis differs somewhat from the 
above. The first and leading principle is the recognition and treat- 
ment of the primary disease. Symptomatically, we must regulate 
the bowels, and keep the parts as clean as possible through copious 
rectal irrigations. It is immaterial whether for this latter purpose 
(of cleanliness) we use permanent rectal drainage with the apparatus 
proposed by Hofmokl (with which, moreover, there seems to have 
been no extensive experience), or the usual double-current cathe- 
ters, or, as described in the G-eneral Division, a simple catheter with 
a T tube similar to that used in stomach lavage. According to 
my own observations, two, or at most three irrigations per day are 
sufficient. The permanent introduction of even a soft instrument 
is so uncomfortable that patients are seldom willing to undergo this 
procedure. 

We have a large variety of antiseptics and astringents to choose 
from : alum, or its double salt, aceto-tartrate of aluminium (2 to 3 
grams per 1,000), sulphate and sulpho-carbolate of zinc (1 to 2 
grams per 1,000), tannic acid (3 to 5 grams per 1,000), nitrate of 



524 DISEASES OF THE INTESTINES 

silver (0.5 to 1 gram per 1,000), etc. A change of solutions some- 
times seems to produce a more rapid cure. 

These irrigations are undoubtedly the most effectual of our 
therapeutic measures ; we may, however, obtain favourable results 
with suppositories containing the above astringents. An ointment 
syringe has been recommended for the same purpose, but in view 
of the application of ointments by the collapsable tin tube (see 
page 484), which has given me the most satisfaction, an " oint- 
ment syringe " seems superfluous. We may in a measure conduce 
to cleanliness, and thus indirectly to the cure of the disease, by 
appropriate medicated sitz baths and by anal douches. In England, 
internal medication with balsam of copaiba, extract of cubebs, or 
oil of turpentine is highly recommended. I have not found it suc- 
cessful in my cases. The use of sea baths and other balneothera- 
peutic measures is practised by balneologists ; but thus far no con- 
vincing proofs of their good effects have been adduced. 

Some cases, especially resistant ulcerative and gonorrhoeal proc- 
titis, are extremely obstinate to all internal therapeutic measures. 

2. Periproctitis 

This is an inflammation of the loose cellular tissue about the 
rectum. Since this tissue is continuous with the fatty tissue which 
fills the ischio-rectal fossa on both sides of the termination of the 
rectum, between the levator ani and the sacral origin of the gluteus 
maximus muscles, the bulbous urethra and the perineal fascia, it is 
evident that local purulent processes may spread extensively. The 
etiological factors are the same as those already described under proc- 
titis. Besides these, periproctitis may also, though now very rarely, 
occur after operations on the rectum which have not been suffi- 
ciently aseptic. Traumatism is also regarded as a cause of periproc- 
titis, particularly since Cruveilhier has described a very marked case 
of this kind, resulting from a " fall on the gluteus." As far as I 
can learn, modern literature — which certainly contains abundant 
cases of accidents — does not present any instance similar to this. 

The inflammatory process may be either acute or chronic, cir- 
cumscribed or diffuse, the acute diffuse type being the most fre- 
quent. 

From the seat of infection, the pus burrows through the cellu- 
lar interstices and extends into the ischio-rectal fossa. The perineal 
fascia offers a slight barrier to the spread of the process, so that the 
anal region is generally affected later than the upper rectal seg- 



DISEASES OF THE RECTUM 525 

ment, about which the pus may spread freely in all directions. 
Under these circumstances the abscess may rupture either exter- 
nally or internally, and thus produce fistulse (q. v.). 

Symptomatology antd Diagnosis 

The symptoms of periproctitis point directly to the seat of the 
lesion. In acute periproctitis the most persistent subjective symp- 
tom is the severe pain, and a feeling of fulness and tension in the 
anus and anal region. The pain becomes unbearable during defe- 
cation, so that patients voluntarily retard this act as much as pos- 
sible. The disease generally begins with a marked chill, accom- 
panied by high fever. When the process is very extensive — an 
occurrence occasionally found in cases improperly treated — the fever 
becomes septic in character. As might be expected, the general 
health soon suffers ; the patients are considerably weakened by the 
fever, anorexia, and loss of sleep, and present the picture of an 
acute infectious disease. 

The objective symptoms are usually very evident. There is 
a more or less hard, reddened, sensitive infiltration about the rec- 
tum. The introduction of the finger causes severe pain, and re- 
veals a hot, swollen mucous membrane, which narrows the lumen 
of the rectum. Bimanual examination elicits fluctuation relatively 
early. In women a vaginal examination may also be made. 

In chronic cases the symptoms are less defined. The abscess 
may rupture without the patient even knowing of the existence of 
a periproctitis or proctitic suppuration. In other cases, however, 
pain during defecation, uncomfortable sensations in the rectal re- 
gion, and a muco-purulent or bloody discharge indicate the char- 
acter and seat of the lesion. 

The diagnosis ought present no difficulty. In every case of 
periproctitis digital examination of the rectum should be made. 
In this manner we may not only discover the cause of the disease — 
e. g., foreign bodies — but its course may be favourably influenced. 
When the sensitiveness is very marked we should always make a 
digital examination in the manner previously described. Narcosis 
is generally unnecessary. If in doubt, we may wait till the time 
of operation, when the whole field can be carefully examined. We 
have already pointed out the importance of the bimanual examina- 
tion (best in the knee-chest position) for eliciting fluctuation. 

The diagnosis of chronic periproctitis is attended by much less 
pain for the patient than the acute. A speculum may be employed. 



526 



DISEASES OF THE INTESTINES 



As in proctitis, so here also it may be difficult to establish the cause 
of the affection (ulcers, fistulge). In the section on Rectal Ulcers 
we shall discuss the symptoms of diagnostic importance. 

Treatment 

The treatment is practically surgical. The well-known anti- 
phlogistic remedies (ice and cold applications to the anal region, 
leeches) are to be applied only in the beginning of the affection — 
i. e., until the first signs of fluctuation appear. Pain is controlled 
by injections of morphin, better by opium suppositories (each con- 
taining 0.03 gram of the extract, introduced every two to three 
hours), or by opiates given internally (tinct. opii, 10 to 15 drops 
t. i. d.). 

When fluctuation is present the abscess should be opened as 
soon as possible. The technic of this procedure is to be found in 
works on surgery. 

3. Rectal Fistulae 

Where an inflammatory process of the rectal mucous membrane 
ruptures externally and produces a pervious canal, we speak of it 

as a rectal fistula. This is the so- 
called complete fistula. Where the 
canal does not extend through to the 
skin, we have an incomplete inter- 
nal fistula. Where periproctitic and 
ischio- rectal abscesses perforate ex- 
ternally, we have an incomplete 
external fistula. The accompanying 
illustrations (Figs. 42, 43, and 44), taken from Esmarch's excellent 
work 3 , illustrate these conditions. 

The causes of fistuloe are similar to those of proctitis and peri- 
proctitis. Ulcerations or abscesses s]owly extend through, and 




42. — Complete Eectal Fistula. 
(von Esmarch.) 




Fig. 43. — Incomplete Internal 
Eectal Fistula. 




Fig. 44. — Incomplete External 
Eectal Fistula. 



finally perforate the different layers of the rectum. The process 
may develop very acutely, and present the characteristic features 



DISEASES OF THE RECTUM 527 

of purulent proctitis already described, or it may be very slow and, 
as mentioned, proceed without the patient's knowledge. Accord- 
ing to Allingham's extensive statistics, a large percentage of fistulas 
(fourteen per cent) are tubercular. It is very important for the 
diagnosis whether the fistula occurs in persons who are otherwise 
well and free from hereditary taint, or whether the fistula is a 
complication of a general, especially pulmonary, tuberculosis. For 
the differential diagnosis and for purposes of treatment a careful 
general examination is required. 

Symptomatolog-y and Diagnosis 

If symptoms of an acute proctitis or periproctitis have been 
present, we should search for rectal fistulas. The diagnosis is more 
difficult when the fistula develops without any previous symptoms. 
It very frequently happens that patients are only accidentally 
prompted to have the rectum examined after the disease has lasted 
a long while. Some discomfort, or a feeling of slight fulness 
in the rectal region before or after defecation, is generally all 
that is complained of. When the fistula is a blind one, and the 
secretions cannot escape, these symptoms may be somewhat in- 
creased in severity. There is a sensation of heat in and around 
the rectum ; the patient has a feeling of painful tension, or even of 
tenesmus. 

The characteristic objective symptom which disquiets the patient 
is the discharge of greater or less quantities of pus from the exter- 
nal or internal fistulous orifice. The pus is generally thin and 
serous, and is rarely mixed with blood or fasces. The discharge 
may cause an annoying intertrigo. Patients occasionally declare 
that they pass gas through the fistula. They are weakened by 
the continual suppuration, feel tired, dispirited, and unwilling 
to work. 

In simple cases the diagnosis is easy ; in complicated cases it 
may be so difficult that the kind and extent of the fistulous tract 
can be recognised only when the patient is under general anaesthesia. 
A careful examination of the anal region and rectum should be 
made. The external orifice of the fistula may be variously situated. 
It is generally in the direct vicinity of the anus, but may be at quite 
some distance therefrom — e. g., at the perinasum or the gluteal promi- 
nence. We ' occasionally meet with several fistulas ; in fact, the 
whole region of the anus may be perforated by numerous orifices. 
The blind external orifice may present a pouting mouth filled with 



528 DISEASES OF THE INTESTINES 

granulations, or it may be a small, barely visible furrow hidden 
between the anal folds, and scarcely admitting a small probe. The 
internal opening is recognised by its small indurated prominence, 
or there may be only a feeling of diffuse infiltration, or no appreci- 
able change in the mucous membrane. In rare cases there is an 
ulceration at the internal orifice of the fistulous tract. Complete 
fistulse are recognised by passing probes through the fistulous canal, 
thus disclosing both its orifices. The best probe for this purpose is 
the flexible one of zinc recommended by Esmarch ; this is gently 
pushed forward, without the use of any force. Quenu and Hart- 
mann 4 recommend thin, soft bougies, like those used in urethral 
catheterization. The left forefinger is introduced into the rectum, 
so that it may follow the direction of the instrument, and thus dis- 
cover a possible internal opening. 

If this does not succeed there may still be a complete fistula, for 
the probe may have followed a false passage. In such cases a 
speculum is introduced and a good light thrown into the rectum, 
and milk or a carmine or eosin solution is injected into the external 
orifice of the fistula. In this connection it is of practical importance 
to know that the internal orifice is usually either in the region of 
the sphincter or directly above it, and that only very rarely is it 
higher than 5 centimetres above the anal orifice (von Esmarch). In 
this manner, we may, by careful and perhaps repeated examinations, 
recognise a complete fistula. This also applies to the incomplete 
external fistulae. The diagnosis of an incomplete internal fistula is 
sometimes much more difficult. The finger when introduced may 
encounter a small indurated, buttonlike prominence, which can, 
however, quite easily escape palpation. At all events, where other 
symptoms indicate fistula, we should not rest until a satisfactory ex- 
planation for the symptoms has been found. In complicated cases 
it will be necessary to make a careful examination under narcosis. 
The diagnosis of rectal fistula alone is not sufficient. As already 
mentioned, we must determine its nature. We should search par- 
ticularly for luetic and tubercular symptoms, which may change 
both prognosis and therapy. 

Treatment 

The treatment of rectal fistulas is now purely surgical. In pre- 
antiseptic times, when operative treatment of these conditions was 
a dangerous proceeding, conservative treatment was attempted. 
The oldest method, known even to Hippocrates and occasionally 



DISEASES OF THE RECTUM 529 

used to this day, is ligation of the complete or artificially completed 
fistula. The other methods — scarification, injections of iodin, nitrate 
of silver, alum, etc. — are all obsolete. With modern asepsis and 
antisepsis, the operation for fistula has lost all danger. The advisa- 
bility of operation is doubtful only when there is advanced tubercu- 
losis, and when other tuberculous ulcerations exist in the rectum. 
In these cases, despite splitting of the fistulous tract, the process 
steadily progresses. The same caution also applies to carcinomatous 
fistulse. In both these latter instances we shall have to limit our- 
selves to symptomatic treatment, particularly to copious irrigation 
of the diseased rectum. A description of the technic of the oper- 
ation for fistula in ano does not belong to this work. 

4. Fissures and Spasm of the Anus 

Small tears or excoriations at the border of the anus may pro- 
duce painful reflex spasms of the anal muscles. In the chapter on 
Intestinal Neuroses we shall see that spastic conditions of the anus 
may also be caused by hysteria, neurasthenia, or diseases of the cen- 
tral nervous system. Fissures are more or less extensive, generally 
oval losses of substance, which are usually superficial, but which 
may also affect the deeper muscular tissues. They are often found 
at the posterior commissure, and less frequently laterally, anteriorly, 
or in the interior of the rectum. After having lasted a long time, 
they increase in size, become indurated, and have a dirty gray base. 
Fissures are generally idiopathic, but may occasionally be pro- 
duced by gonorrhoea, syphilis, tuberculosis, hemorrhoids, etc. They 
occur in both sexes, more often in women than in men, and are 
not infrequently found in early childhood. 

Habitual constipation predisposes to fissures, particularly when 
there is a disproportion between the calibre of the fasces and the 
anal opening. A soft, irritable skin also favours their development. 
These conditions are more often present in women, hence the 
greater frequency of fissures among the latter. According to von 
Esinarch,* fissures frequently occur in women who suffer from ante- 
version or retroversion of the uterus. The act of parturition, dur- 
ing which the rectal region and anus are enormously stretched, may 
easily produce fissures. 

* Loc. cit., p. 148. 



530 DISEASES OF THE INTESTINES 

Symptomatology and Diagnosis 

Anal spasm is recognised by the paroxysmal pains which accom- 
pany defecation. The patients liken them to that of a red-hot iron 
boring through the anus. The pain may be limited to the anus, or 
radiate to the bladder, the external genitals, or the legs. The pa- 
tients try to suppress defecation and the passing of flatus, so that 
these cases sometimes have marked abdominal distention. Rest 
relieves the pain ; motion, or even sitting for a long time, may in- 
crease it. 

The fissure can be discovered by careful inspection or digital 
exploration of the rectum. Where digital examination is very pain- 
ful, or where the finger can with difficulty be passed through the 
anal orifice, it is better to previously relieve sensitiveness by the 
introduction of a thin suppository of opium and cocain, or by 
cocain ointment spread over the rectal mucous membrane with the 
previously mentioned collapsable tin tube. According to von Es- 
march, a small polypoid tumour or an edematous fold of the skin 
of the anus is often found at the external extremity of the fissure. 
The fissure becomes visible only when this growth or fold is drawn 
aside. I can recall but one such instance. For the purpose of 
more thorough examination, surgeons (von Esmarch and others) 
advise narcosis. Personally I have always found the above-men- 
tioned methods sufficient. It appears to me that narcosis is only 
indicated in those rare forms in which the fissure is situated higher 
up. It is of diagnostic importance to determine whether the fissure 
is idiopathic, or secondary to gonorrhoea, lues, tuberculosis, or hem- 
orrhoids. 

Treatment 

Prophylaxis is of the first importance. In those suffering from 
habitual constipation, that condition must be treated upon the prin- 
ciples already enunciated (see chapter on Constipation). The tis- 
sues of the anal and rectal regions must be hardened by washing 
with solutions of tannin and alum, or with soaps containing these 
substances, and by sitz baths. The patients must avoid severe strain- 
ing during defecation. 

When a fissure has been discovered, the anal region must as far as 
possible be immobilized ; the patient should remain in bed till cured. 
A second preliminary condition to recovery is the artificial preven- 
tion of defecation (see page 157). The patients are put upon a fluid 



DISEASES OF THE RECTUM 531 

diet, and get ten drops of tincture of opium three times daily. Of 
late I have returned to the use of opium suppositories. If the fis- 
sure can be seen, it is best dusted with some dry powder (e. g., airol, 
xeroform, iodoform, orthoform, calomel, etc.), without directly 
touching the fissure with the fingers. I have seen more harm than 
good from washing with antiseptic solutions. 

After a week of this treatment I give the patients a large dose 
of castor oil, and advise them to attempt to pass stool only when 
they feel that the fasces have become thoroughly softened. Under 
all circumstances straining must be avoided. The first evacua- 
tion is usually painless. Sometimes the entire treatment must be 
repeated a second or even a third time. I can warmly recommend 
this method, although some individuals cannot retain their stools 
for a week ; in these treatment is generally unsuccessful. Of 12 
cases of fissure whose histories I possess, 6 recovered within eight 
to ten days, 2 were cured in three weeks, 2 in four weeks, and 
only 2 had to be operated. I believe it incorrect to regulate the 
bowels by purgatives. 

Local treatment with various astringent, cauterizing, and anaes- 
thetic agents has been recommended. The most frequently used is 
cauterization with the pure nitrate of silver, or with a ten -per- cent 
solution of the same. Allingham 5 employs the following : 

Calomel 0.25 

Pulv. opii 0.10 

Ext. bellad 0.10 

Ung. sambuci 5.00 

m 

This ointment is to be frequently spread over the entire anal 
surface. Yan der "Willigen 6 , and recently Conitzer 7 , recommend 
pencilling twice daily with a brush dipped in pure ichthyol. I have 
twice seen good results from this method, but in a third advanced 
case of fissure it was useless. Cases which are not cured by any of 
the above methods require radical treatment. A bloodless method 
consists in stretching and massaging the anal sphincter under narco- 
sis. This procedure, which is often employed in France, and is also 
highly recommended by Allingham 5 and von Esmarch 3 , is rarely 
used in Germany. The most certain method is the splitting of the 
fissure with a knife or thermocautery [Paquelin], after which heal- 
ing is usually quite rapid. 



532 DISEASES OF THE INTESTINES 

5. Ulcers of the Rectum 

Ulcers of the rectum occur under the most varied conditions — 
primary, secondary, limited to the rectum, or involving other seg- 
ments of the large intestine. 

Primary rectal ulcers are traumatic (from enemata or foreign 
bodies), gonorrhoea^ and syphilitic (both from sodomy). Gonor- 
rhoea! and syphilitic ulcerations may also develop indirectly (Bar- 
tholinitis, recto-vaginal fistula, breaking down of large condylomata, 
etc.). Among secondary ulcerations are the tubercular, which always 
result from auto-infection. Finally, there are the dysenteric and 
follicular ulcers, which also occur higher up in the intestines. These 
various types require a brief individual description. 

1. Dysenteric ulcers result from chronic dysentery, ulcerative 
destruction of the rectal mucous membrane, or from a follicular 
catarrh. By destruction of the follicles and confluence of the 
destroyed areas there gradually develop deep and extensive ulcera- 
tions. The rectal lesion is always secondary to involvement of 
other portions of the large intestines. The ulcers may extend into 
the serous coat, and produce perforative peritonitis, abscess, and 
fistula, or subsequent cicatricial stenosis. 

2. Follicular ulcers develop in the rectum and large bowel 
where there is catarrh with marked swelling of the follicles. When 
these follicles rupture, a small flat ulcer results. Several such 
ulcers coalesce and produce larger ulcerations, which, by the persist- 
ence of the catarrh or through other unfavourable circumstances, 
may become quite deep, and even rupture into neighbouring organs. 
As von Esmarch 3 states, these ulcers are sluggish in character, heal 
badly, and lead to the formation of cicatrices and polypi. Accord- 
ing to this authority, most cases occur toward the end of exhaust- 
ing diseases or after severe injuries and operations, and produce 
death by colliquative diarrhoeas. 

Follicular ulcers are frequent in children with chronic diar- 
rhoea. I have never observed this form of ulceration in adults, not 
even in those suffering from severe catarrh of the large intestine. 
On the other hand, I have repeatedly seen chronic follicular swell- 
ing, with pain and other disturbances, in catarrh of the large intes- 
tine and rectum. 

3. Tubercular ulcers (see Fig. 45). These result from swallowed 
tubercular sputum or from tubercle bacilli which have reached the 
rectum by means of the blood and lymph channels. Mechanical in- 



DISEASES OF THE RECTUM 



533 



suits to the anus or rectum are predisposing factors. In the case 
from which the accompanying illustration is taken, the probable cause 
of the lesion was continued contact of the anal mucous membrane 
with mechanically and chemically irritating evacuations. The patient 
suffered from intestinal tuberculosis. The ulcers are formed by the 
breaking down of tubercular nodules (lenticular ulcer). Similar to 
tubercular ulcers of the rest of the intestine, those of the rectum are 




Fig. 45.— Tubercular Anal and Eectal Ulcer, with Hemorrhoidal Nodule. 
(Original observation.) 

characterized by a circular arrangement. ^N"ear the ulcers fresh 
tubercular, grayish, globular nodules occasionally develop, undergo 
the same necrotic process (softening, fatty and caseous degenera- 
tion), and produce secondary tubercular ulcers. \Ye have already 
mentioned that tubercular ulcerations tend to spread, and to cause 
periproctitis and rectal fistulae. 

4. Syphilitic ulcers of the rectum occur in the most varied 
35 



534 DISEASES OF THE INTESTINES 

forms. They very rarely result from a primary infection (hard 
chancre) in coitus per anum, but are more frequently caused by in- 
fection from the secretion of a chancre or by the breaking down of 
brood condylomata in the neighborhood of and spreading toward 
the anus. They may occur as gummatous ulcers. Gummata may 
be found in various stages : true gumma, degenerated gumma, 
superficial ulcer, or scar tissue from old healed ulcerations. Fre- 
quently we can also distinguish the more recent processes (rounded 
nodules with beginning ulcerative degeneration, and containing 
necrotic, brownish-red masses) from the older, deep, irregular 
ulcerations. 

In constitutional syphilis there may be a proliferation of the 
deep layers of the connective tissue, a condition von Esmarch 3 des- 
ignates as gummatous or syphilitic polypi. Unlike true rectal 
polypi, these do not originate in the mucous membrane, but from 
a proliferation of the submucous, submuscular, or subserous cellular 
tissue. Yirchow has therefore called them granulation tumours 
(granulomata). When these heal, cicatrices, which may produce 
extensive stenosis, develop ; these will be described later. In 
marked cases the entire rectum is changed into a rigid, immovable 
funnel with immensely thickened walls. If the lowermost portion 
of the rectum is affected, complete destruction of the sphincter 
may result. 

5. Gonorrhoea! ulcers. Opinion is divided as to whether rectal 
ulcers may be gonorrheal or not. While Jullien 1 believes in their 
existence, Baer 2 considers them complications (post-gonorrhoeal 
ulcerations), particularly since no gonococci have been demonstrated 
in the excised portions. According to Baer, these ulcers are usually 
situated upon the anterior or posterior wall of the anal orifice upon 
a protrusion of its mucous membrane or of a hemorrhoidal fold. 
The surface of the ulcer is always directed toward the lumen of the 
rectum. 

Symptomatology and Diagnosis 

The first symptom observed in uncomplicated ulcer of the rec- 
tum is a change in the evacuations. The stools are generally thin 
and fluid, are mixed with blood and pus, have a very fetid odour, 
and may consist only of blood and pus. In addition, there is more 
or less marked tenesmus and pain radiating to the bladder, back, 
legs, and genitals. The subjective symptoms may be absent, or 
may not be prominent. As a result of hemorrhage and suppura- 



DISEASES OF THE RECTUM 535 

tion, and occasionally from fever, the patients lose considerable 
flesh and strength. From the symptoms above enumerated we may 
assume the presence of ulcerative processes in the rectum. For 
positive diagnosis a local examination is, however, necessary. 

Careful digital exploration, whereby the situation and nature 
of the ulcers can be fairly well determined, is the best method of 
examination. It is also desirable to inspect the mucous membrane 
by means of a speculum, the rectum being meanwhile irrigated 
with water. In this manner the diagnosis of tubercular, syphilitic, 
or catarrhal ulceration can usually be made although great difficul- 
ties may be encountered. 

A thorough history and careful study of the other clinical symp- 
toms are of the utmost importance, particularly in the differentiation 
between syphilitic, dysenteric, and tubercular ulcers. We must 
always search for other signs of syphilitic or tuberculous disease. 
When ulcers appear gonorrhceal, the secretion should be examined 
for gonococci. Similarly the tubercle bacillus must be looked for. 
Small portions of the ulcers may have to be excised for microscop- 
ical examination, although positive results are not always obtained. 
Since ulcerations may also occur from ruptured abscesses (salpin- 
gitis, Bartholinitis), vaginal examination must never be omitted. 

Treatment 

The treatment of ulcers of the rectum is very tedious. The 
reason is evident. The rectum offers the best chances for the 
propagation of ulcerative processes, but the worst for their cure. 
The long list of remedies that have been recommended bears out 
the above assertion. 

A priori, the aim of our therapy would seem simple enough — 
viz., wherever possible, to eradicate the underlying cause. Where 
this is not possible, energetic local treatment should be instituted. 

Prophylactic treatment is often employed in tuberculosis and 
syphilis, but, unfortunately, with little success. The chief cause 
for this is that patients regard the first phases of their rectal affec- 
tion too lightly, and therefore present themselves for treatment 
when the disease is already far advanced. In tubercular rectal 
ulceration the patients usually have pulmonary or intestinal tuber- 
culosis, so that treatment will be of little avail. 

The conditions are more favourable in ulcerating chancres ; 
these may be healed by appropriate anti- syphilitic treatment (Kob- 
ner). Although occasionally cured by energetic use of iodids by 



536 DISEASES OF THE INTESTINES 

mouth and rectum, gummatous ulcers do not as a rule respond well 
to treatment. 

The treatment of gonorrheal ulcers is the same as that of anal 
gonorrhoea — i. e., astringent and antiseptic solutions. According 
to Baer and others, the results are not more satisfactory than in 
chronic urethritis. 

Symptomatic treatment should be directed toward the increase 
of general health and strength and the regulation of the bowels. 
The most difficult therapeutic problem is the cure of the ulcers by 
local treatment. The number of preparations recommended for 
this purpose is so large that we can only mention the most impor- 
tant and usual ones. These include nitrate of silver, sulphate of 
zinc, tannin, aceto-tartrate of aluminium (Boas), zinc-chlorid solu- 
tions, and carbolic acid. They are best applied in the form of rec- 
tal irrigations. Allingham recommends the use of soft ointments 
applied by a specially constructed ointment spray. 

The difficulty in local treatment lies in the fact that in advanced 
cases constrictions and dilatations almost always prevent remedial 
agents from reaching the main seat of the disease. Surgical meth- 
ods have therefore been attempted. In marked stricture of the anal 
orifice, in order to render the diseased area more accessible, poste- 
rior sphincterotomy has been proposed. In ulcerations higher 
up, the most appropriate treatment would seem temporary colos- 
tomy, with subsequent local treatment through the intestinal fistula. 
Except in cases of stenoses (see below), but little experience with 
this operation has been gathered. When, as in rectal stenosis, the 
disease is very extensive and obstinate, and remains uninfluenced 
by all palliative measures, the only remaining procedure is resec- 
tion of the ulcerated portion. 

6. Strictures of the Rectum 

The causes may be external or internal. External conditions 
are disease of neighbouring organs, prostatic hypertrophy, neo- 
plasms, plastic exudates, and vesical calculi. Internal stricture may 
be produced by simple obstruction of the lumen of the rectum, by 
faecal masses, foreign bodies, enteroliths, and tumours, or by inflam- 
matory conditions of the rectum itself. The latter are undoubtedly 
the most frequent causes of stricture, and therefore merit thorough 
discussion. 

All lesions of the rectum which heal by granulation must pro- 
duce narrowing of its lumen. Wherever a stricture has developed, 



DISEASES OF THE RECTUM 537 

its increase is favoured by continued irritation of the adjacent 
tissues or by an extension of the underlying disease. 

We have previously described (page 49±) the various kinds of 
ulcerations of the rectum. Syphilitic and dysenteric ulcers are far 
more apt to produce extensive stenosis than are tubercular. To 
what extent gonorrhceal processes produce stenosis is still a dis- 
puted question. 

Xo doubt there is an inflammatory rectal stenosis similar to 
inflammatory pyloric hypertrophy or to the so-called multiple 
submucous sclerosis of the French. In his latest work, Bushe* 
describes a very characteristic case. Eieder 8 also believes in the 
existence of a chronic inflammatory proctitis with destruction of 
the mucosa and proliferation of the sub mucosa and muscularis. 

The stricture is usually situated directly above the anal orifice, 
but may even be as high up as the sigmoid flexure. (Several years 
ago I saw an instance of this latter condition in a young woman. 
The etiology of the case could not be determined.) The strictured 
segment may be either straight, corkscrew shaped, or arborescent. 
The wall of the canal may consist of thick, indurated mucous mem- 
brane without ulcers, or there may be numerous primary or sec- 
ondary erosions. In the most complicated cases all possible patho- 
logical changes may be combined — viz=, proctitis, periproctitis, fis- 
sures, hemorrhoids, fistulse, etc. 

The greatest number of rectal stenoses are found in women with 
present or previous syphilitic symptoms. In the former instance 
syphilitic ulcers or gummata may be found on the genitals and in 
the rectum, or in the rectum alone. These conditions are not dif- 
ficult to diagnosticate, although the manner in which the syphilitic 
virus infects new areas may not be apparent. According to Quenu 
and Hartmann 4 , the lower group of rectal veins anastomose directly 
with branches of the external pudendal, which latter originate in 
the posterior commissure of the vulva, the chief seat of syphilitic 
infection. 

The question of post-syphilitic strictures has caused very much 
discussion, and at the present time all etiological factors have not 
been agreed upon. We can, however, safely say that syphilis is 
undoubtedly the cause of a large number of rectal strictures. The 
fact that the above lesions frequently occur with other syphilitic 
stigmata ' (exostoses, amylosis, endarteritis, syphiloma of the liver, 

* Loc. cit. page 109. 



538 DISEASES OF THE INTESTINES 

etc.) indicates their close association with constitutional syphilis. 
The objection of the opponents of this theory (Nickel 9 , Polchen 10 ), 
that rectal stenoses are refractory to specific treatment, is hardly 
convincing. The theory that rectal ulcers are produced by trauma- 
tism does not explain their greater occurrence in women. We ad- 
mit that, besides syphilis, gonorrhoea and catarrhal inflammations of 
the rectal mucous membrane may produce strictures. Rieder 8 has 
recently demonstrated that there is a proliferation of the intima of 
the rectal veins, even to complete obliteration, while the arteries 
remain intact. This condition he considers characteristic of syph- 
ilitic rectal stenosis. 

Symptomatology and Diagnosis 

Obstruction to defecation is the foremost symptom of stricture 
of the rectum. 

As in carcinomatous strictures (already discussed on page 318), the 
early symptoms of these rectal strictures are obscure and generally 
escape observation. The patients first present themselves for treat- 
ment when symptoms of ulceration or of increasing rectal stenosis 
become prominent. In the former instance there is a bloody, mu- 
cous, or purulent discharge ; in the latter, painful tenesmus with 
fragmentary, scybalous, small-calibred or semifluid dejections. The 
symptoms of ulceration may be accompanied by those of stricture. 
Above the stricture (in the sigmoid flexure or higher) abdominal 
palpation reveals faecal masses, which soon produce a sacculated 
dilatation of this part of the large intestine — an important symptom 
of low strictures. There may be so-called " false diarrhoeas," which 
are easily mistaken for intestinal catarrh. 

The general health is gradually undermined by the tenesmus 
and loss of blood and pus. It is surprising, however, to note how 
long the general condition of patients with non-malignant strictures 
remains good. This applies also to malignant strictures, though 
here we may generally detect the characteristic cachexia. Acute, 
complete stenoses or perforations into the neighbouring organs may 
take place, but are rare. The lower the stenosis the more infre- 
quent these perforations. 

Continued ulceration may cause extensive destruction of the 
sphincter ani. The symptoms of rectal incontinence then appear, 
tenesmus ceases, and there is a profuse, continuous discharge of 
blood, pus, and mucus. 

The diagnosis of rectal stricture is readily made. Upon intro- 



DISEASES OF THE RECTUM 539 

duction, the finger immediately strikes an obstacle; at the same 
time we are informed of the degree of the stenosis, at least of its 
lower (anal) portion. To determine the size of the stricture and 
the condition beyond, the introduction of rectal bougies is indis- 
pensable. As already mentioned (page 81), we may use various 
instruments for this purpose. We should always remember that 
we are introducing the instrument into a cavity whose length, 
direction, and lateral recesses are unknown, and that by this pro- 
cedure we cannot determine the condition of the rectal wall and 
the presence, extent, and depth of the ulcerations. Considering all 
these facts, we may ask whether the diagnostic value of instrumen- 
tation is as great as its dangers. It is plain, however, that thera- 
peutic bougieing has to reckon with other factors. Bougieing is 
only absolutely necessary in strictures beyond the reach of the 
examining finger, for here the diagnostic difficulties cannot other- 
wise be overcome. Thus the previously mentioned case of sigmoid 
stricture (page 512) had passed through many hands before the cor- 
rect diagnosis was made. We have already pointed out the charac- 
teristics of stricture of the sigmoid flexure and of the upper part 
of the rectum (page 82). I agree with experienced clinicians that 
the use of a speculum is generally unnecessary for the diagnosis of 
low-seated strictures, although one may thus obtain a better idea of 
their character. 

The examination of the dejections, their form, and more espe- 
cially the admixture of purulent, fetid, bloody masses, completes 
the clinical picture and diagnosis. As already stated, changes in 
the stools are often the first symptoms to alarm the patient, and 
should always lead to careful local examination. 

Differential Diagnosis 

The etiology of strictures is much more difficult to determine 
than is their diagnosis. Since they will scarcely escape a careful 
examination, we need not here consider external tumours, exudates, 
etc., which constrict the rectum. Prostatic tumours and enlarge- 
ments will likewise rarely cause error in diagnosis, but differen- 
tiation between malignant and benign rectal strictures, particularly 
between carcinomatous, luetic, gonorrhoea^ and dysenteric varieties, 
is quite difficult. 

In distinguishing between malignant and non -malignant ste- 
noses, the history and clinical course of the disease are frequently of 
value. The existence of syphilitic infection or of a previous dysen- 



540 DISEASES OF THE INTESTINES 

tery can usually be established. The course of the affection is more 
important. The patients may state that their symptoms date back 
several years — a fact of great significance as regards the kind and 
character of the stricture. The age of the patient and the absence 
of cachexia may to some extent speak for one or the other type of 
stenosis. 

As we have seen in the section on Cancer of the Rectum (page 
321), digital examination may give us useful information — e. g., in 
the differentiation between carcinomatous and syphilitic strictures. 
Nevertheless, errors may occur. In such cases excision and micro- 
scopical examination of a rather large piece of the new growth may 
make the diagnosis positive. 

The differential diagnosis between syphilitic and dysenteric rec- 
tal strictures is very difficult. In his work on tumours, Yirchow 12 
states : " Gummatous ulcers resemble diphtheritic, and more espe- 
cially dysenteric, ulcers. This similarity is so marked that I have 
often been in doubt as to whether the destructive process in a given 
case was syphilitic or dysenteric. The same is also true of stric- 
tures. The site of the lesion may to a certain extent guide us. In 
dysenteric processes the lesions are more frequently found in the 
sigmoid flexure ; in syphilitic, in the ampulla of the rectum or close 
to the anus. In addition, the more even and broader ulcerations of 
syphilis contrast with the eroded, irregular, superficial and deep 
ulcerations of dysentery." In view of the rare occurrence of 
dysentery in our country [Germany] the clinical differentiation will 
usually be easy. 

Tubercular rectal stenoses are rare, and are generally accom- 
panied by signs of tuberculosis in other portions of the body (lungs, 
peritoneum, other intestinal segments, genito-urinary system, etc.) ; 
the etiology of the ulcers may be determined by examination of the 
secretion for tubercle bacilli. When suspecting gonorrhoea! stric- 
ture, gonococci should be sought for. It must not be forgotten, 
however, that, especially among prostitutes, the simultaneous occur- 
rence of syphilis and gonorrhoea is by no means rare. 

From the above data we may (perhaps after a long-continued 
observation), in many cases, make a probable or even a positive 
diagnosis. 

Treatment 

Whatever the nature of the underlying process, internal treat- 
ment of strictures of the rectum is useless. Most experienced 



DISEASES OF THE RECTUM 541 

clinicians agree npon the futility or slight value of antisyphilitic 
treatment. According to dermatologists, in order to prevent cica- 
tricial contraction, radical antisyphilitic treatment is always in- 
dicated in fresh gummatous syphilis. In the majority of cases we 
must alleviate stenotic symptoms by laxatives. Drastic drugs are 
to be avoided. Rhubarb, frangula, flowers of sulphur, compound 
licorice powder, or magnesia usta, in conjunction with the so-called 
" constipation diet " (see page 146), are usually sufficient. If, as 
determined by external palpation, there is long-standing coprostasis, 
the safest procedure is the administration of large doses of castor 
oil (2 to 3 tablespoonfuls, repeated, if necessary, for several days). 

The best palliative measure is methodical dilatation of the 
stricture by rectal bougies. Views differ widely regarding the 
value of this method. Most surgeons do not adopt the extreme 
view of Schuchardt, Rieder, and others, that bougieing should be 
entirely discarded. In several cases of very advanced luetic stric- 
ture I have achieved remarkably favourable results with sounds, 
although the treatment had to be carried out three times a week for 
several months. I consider proctitis or periproctitis positive con- 
traindications to the use of bougies. In a dissertation upon the clin- 
ical material of Gr. Lewin, Alderhot 12 also speaks in favour of bou- 
gieing. Before beginning treatment, it is advisable to point out to 
the patient the length of time required, as well as the possibility of 
relapses after bougies have been discontinued. If the patient is 
intelligent, he may after a few weeks be intrusted with the instru- 
mentation himself, and the result occasionally controlled by the 
physician. We begin with the smallest bougie that will pass the 
stenosis, gradually increasing the size. The instrument should be 
left in situ several minutes, and, to aid in the dilatation, should be 
given gentle rotary movements. 

The best bougies are solid soft-rubber ones, purchasable every- 
where, or Hahn's hollow bougies containing a spiral frame. The 
latter are not soft enough to give way when they encounter the 
obstruction, but are sufficiently elastic not to cause laceration. If 
properly curved (Bushe), the following instruments are also rec- 
ommended : French bougies, hard-rubber or glass bougies (von Es- 
march), and olive bougies fashioned after Trousseau's sounds. Crede 
and Korte prefer curved, hard-rubber bougies. Because of their 
lack of danger soft instruments are to be preferred. Where dis- 
charges of blood or pus weaken the patient, we may try astrin- 
gent irrigations (aceto -tartrate of aluminium, tannin, nitrate of 



542 DISEASES OF THE INTESTINES 

silver) ; for obvious reasons, however, such irrigations are of little 
benefit. 

If the above palliative measures cannot be applied, or have 
proved futile, we should advise operative treatment. There are 
several methods ; opinion regarding their respective value is as 
yet divided. 

These methods are the following : (a) Lateral incision with a 
scalpel in order to render bougieing easier. This has not met 
with great favour, since superficial incisions are of little use and 
deep ones dangerous, (b) In annular cicatricial stenosis of the 
anus, Dieffenbach advocated extirpation of the stricture and draw- 
ing down and suture of the distal mucous membrane to the lower 
edge of the wound, (c) In very marked stenosis of the anal region 
and of the lower portion of the rectum, Pean recommended that 
the canal should be cut longitudinally and the cut edges sutured 
transversely, similar to the pyloroplasty of Heineke-Mikulicz. 
This method, however, presupposes a stenosis of equal degree 
throughout and the absence of fistulse, and hence will be of use 
in only a limited number of cases. (c7) Colostomy. This is usually 
not dangerous, but is functionally unsatisfactory. The method first 
used by Thiem 13 — temporary colostomy and subsequent bougieing 
of the stenosis — gives much better results. As soon as the stenosis 
is cured (cure naturally proceeding much more quickly under these 
circumstances) the artificial anus may be closed. At present this is 
the best and undoubtedly the most preferable procedure, because it 
is not dangerous, and gives the best functional results. It is doubt- 
ful, however, whether the majority of stenoses can be sufficiently 
dilated to permit the normal passage of fseces within a reasonable 
time. Further experience in this field is necessary. 

Sonnenburg 14 , and recently Eotter 15 , have proposed two methods 
whose value can only be determined by future operations. 

(e) In very extensive syphilitic (and gonorrhoeal) strictures, 
which, owing to their high situation and extent, cannot be extirpated, 
Sonnenburg recommends extirpation of enough of the coccyx and 
sacrum to lay bare the callous stricture and its surroundings. On 
account of the extensive adhesions present, the peritoneum is not 
endangered. The whole length of the stricture is then divided 
from without inward ; the sphincter is not divided. The wound 
is tamponed, and heals slowly. Later, long-continued bougie- 
ing is necessary. Sonnenburg calls this operation " external rec- 
totomyP 



DISEASES OF THE RECTUM 543 

(f) Following the principle recommended by the American sur- 
geon Bacon, Rotter connects the intestinal segment above the stric- 
ture (the sigmoid flexure portion) with the normal segment lying 
between the stricture and sphincter ani. In two out of three cases 
this operation was successful, and was accompanied by good func- 
tional results. Rotter calls his operation "sigmoid rectotomy" 
Aside from the fact that this procedure circumvents but does not 
remove the stricture, it has a limited application, for it can only be 
used when there is enough healthy rectum above the sphincter ani 
for implantation of the sigmoid flexure and it is no longer possible 
to treat the stricture. 

(g) The most thorough and at the same time most severe opera- 
tion is resection of the rectum, first performed by James Israel in 
1885, and since then repeatedly by Schede 16 and many others. 
When we consider the difficulties of this operation, the results 
achieved by Schede are quite satisfactory. In 17 cases from 
Schede's clinic, recently reported by Rieder 8 , none died from the 
operation. Permanent results were obtained in 10 cases ; of these, 
5 remained cured and free from recurrence ; the remaining 5 had 
either relapses or fistulse. Of the 5 cured cases (4 of them were 
positively syphilitic) 1 was well since one year, 2 others since two 
years, and 2 since six years. It is very difficult to obtain a good 
functional result after the operation. 

It is only from rectal examination that we can, in a given case, 
determine which of the above operations is the most appropriate. 
Besides, the surgeon is swayed by his preference for one or the 
other operation, and by his own results. 

7. Prolapse of the Rectum {Prolapsus Recti) 

The rectum is so closely connected with surrounding tissues that 
only under special conditions is this attachment loosened. Such 
conditions are for the most part found in children. According to 
the statistics of Bokai 17 , of 350 cases of prolapsus recti, the greatest 
number occurred in children in the second and third years of life, 
the first and the later years showing a markedly diminished predis- 
position to the affection. Other prominent etiological factors are 
poor general health, constipation, respiratory diseases (especially 
pertussis), and catarrh of the large intestine (particularly of the 
rectum) with severe tenesmus. 

In adults, besides the above factors, there are dysuria, unnatural 
coitus, senile atrophy of the muscles of the pelvic outlet (levator 



544 DISEASES OF THE INTESTINES 

ani, rectal sphincters, and retractors) ; in women, overdistention of 
the muscles of the pelvic floor, etc. 

The prolapse generally develops gradually; at first the anal 
mucous membrane protrudes (as it does physiologically in the horse 
during defecation) ; later there is a protrusion of all the layers of 
the rectal wall. In extensive rectal prolapse the peritoneal fold of 
Douglas is also drawn down. The sac formed in this manner may, 
in rare instances, contain intestine, ovaries or bladder — a condition 
known as rectal hernia. True rectal is to be sharply distinguished 
from hemorrhoidal prolapse, the latter being easily differentiated 
by the well-marked bluish nodules. "We shall later return to the 
subject of hemorrhoidal prolapse. 

Symptomatology and Diagnosis 

The first symptoms are usually not well marked, and hence 
have rarely been observed. The patient's attention is directed 
to the lesion only when large portions of the rectum prolapse and 
are not spontaneously reduced. On straining, we may then dis- 
tinctly see the rosettelike protrusion of the mucous membrane with 
the central opening from which fseces are emptied. When the pro- 
lapse is reduced the examining finger can easily recognise the relax- 
ation of the sphincters. At first the prolapse occurs infrequently, 
and only from severe straining at stool ; gradually the resistance of 
the sphincters is more easily overcome, so that coughing, laughing, 
sneezing, and even walking, cause protrusion. 

In consequence of mechanical irritation, particularly in the be- 
ginning of the disease when the rectum is unaccustomed to any for- 
eign influences, inflammation with subsequent catarrh of the mucous 
membrane may develop. A copious discharge of viscid mucoid se- 
cretion follows. Accompanying this condition there may be hemor- 
rhages, ulceration, and, where long-continued incarceration exists, 
gangrenous inflammation with necrosis of the prolapsed segment 
and serious sequelse. In this manner spontaneous cure often re- 
sults. In the last stages of the disease, having gained a certain 
amount of practice in the rapid reposition of the prolapse, the pa- 
tient becomes more or less accustomed to the condition. 

We can gauge the age of the prolapse by its characteristics. 
During the first stages it is succulent, soft, covered with mucus, and 
rich in blood supply ; later it becomes tough, smooth, and resembles 
epidermis. This latter condition favours easy reduction. 

The occurrence of prolapse with simultaneous descent of abdom- 



DISEASES OF THE RECTUM 5^5 

inal contents is of clinical importance. In such cases the prolapse 
increases in size ; the orifice of the rectum is then pushed toward 
the coccyx, and does not regain its axial position till the hernial 
contents are reduced. If, as the result of marked distention or 
inflammation of the rectum, or of abnormal tension of the sphincter 
or levator ani, the intestinal contents become incarcerated, all the 
sequences of intestinal strangulation may ensue. 

The diagnosis of prolapsus recti is rarely difficult. Careful ex- 
amination will nearly always prevent error in differentiating between 
rectal and hemorrhoidal prolapse. In extreme rectal prolapse it is 
often difficult to determine whether or not intestinal contents, etc., 
are present in the peritoneal sac. There are numerous reports of 
unsuccessful operations due to this error. Careful and repeated 
examinations (preferably under anaesthesia) are therefore necessary. 

Intussusception of the colon must be considered, as it frequently 
occurs during the earlier periods of life. There is considerable 
difference in the course of these two diseases (see page 387), and 
difficulty in their differentiation can only arise when we have 
neither reliable history or observation to guide us. In intestinal 
invagination the examining finger can feel the rectum outside the 
intussusceptum without meeting the point of reduplication. It is 
important also to note that in prolapse there is a sort of furrow 
between the base of the prolapsed portion and the anal ring, which 
furrow disappears only in long-standing cases. In a prolapsed and 
invaginated colon a bougie may be introduced for a long distance, 
while in rectal prolapse the instrument's progress is soon stopped. 

Treatment 

This is most successful during the early stages. At such times 
cure may be obtained by regulation of the bowels, careful avoidance 
of straining, and by local tonic treatment (cold irrigations with astrin- 
gent solutions, etc.). Unfortunately we usually see cases for the 
first time when they are far advanced, and when they are much less 
amenable to conservative treatment. 

The age of the individual and the duration of the prolapse have 
an important bearing upon the treatment. In very old prolapses, 
where operation is declined, internal treatment can only be symp- 
tomatic. In children in whom the prolapse is not very far ad- 
vanced, active internal or surgical measures are always indicated. 

Besides careful regulation of the bowels (one semisolid move- 
ment daily) and thorough regional treatment with astringents, local 




546 DISEASES OF THE INTESTINES 

subcutaneous injections of ergotin (0.1 gm. to 0.2 gm. per dose) or 
strychnin (0.001 to 0.002 gm.) may be given. This treatment has 
often been successful, and is worthy of systematic trial. Should 

it fail, surgical measures must 
be employed. The rectal sup- 
port of von Esmarch (see Fig. 
46) is the best means of con- 
trolling the prolapse in pa- 
tients who complain mainly of 
the discomfort. 

In my opinion, the indica- 

Fig. 46,-Eectal Support, (von Esmarch.) tion for Surgical treatment, 

which nowadays has entirely 
superseded the former bloodless methods (actual cautery,* cauteri- 
zation with mineral acids, etc.), depends upon the severity of the 
symptoms. The prolapse jper se is certainly no indication for opera- 
tion, for I have seen patients become entirely accustomed to their 
condition. 

The question of operation is quite different where there is diffi- 
culty in replacing the prolapse, where there is any inflammation or 
hemorrhage, and where the bowel protrudes in the interval of 
defecation. We should lose no unnecessary time with palliative 
treatment, especially since the present state of surgery has robbed 
this operation of its dangers. Unfortunately, operation does not 
always guard against relapses. For the various operative procedures 
the reader is referred to surgical text-books. 

8. Hemorrhoids 

These are diffuse or circumscribed dilatations of hemorrhoidal 
veins situated in the subcutaneous tissue of the outer anal region and 
in the submucous tissue of the lower rectal segment. The old 
classification of hemorrhoids into external, internal, and mixed 
groups still holds good. In mixed hemorrhoids the extra-rectal 
portion is usually small and the intra-rectal portion well developed. 
We find the statement, particularly in older literature, that hemor- 
rhoids may extend over the entire rectum and even into the sigmoid 
flexure. If this condition occurs at all, it certainly is extremely 

* [This certainly is a surgical procedure — in fact, the cautery operation at the 
present time is the favourite method in the United States for uncomplicated rectal 
prolapse. — Tr.] 



DISEASES OF THE RECTUM 5±7 

rare. For the most part hemorrhoids are undoubtedly caused by 
hindrance to the return of blood to the vena cava and portal vein. 
We distinguish, 

1. Internal causes, within the rectal mucous membrane. 

2. External causes, which act by compressing the hemorrhoidal 
plexus. 

3. Disturbances of the general circulation. 

Internal factors produce three quarters of all hemorrhoidal for- 
mations. Fsecal stasis is the most important and frequent of these 
causes. A vicious circle develops ; coprostasis, pressure on the 
hemorrhoidal veins (further increased by straining of the abdominal 
muscles), and formation of hemorrhoidal nodules, followed by 
mechanical intestinal stenosis, stasis, proctitis, increased constipa- 
tion, etc. 

Other changes in the mucous membrane of the rectum and other 
parts of the large bowel (stenosis, new growths, foreign bodies, 
prostatic enlargement), by preventing the normal passage of faeces, 
may give rise to hemorrhoids. As in cancer of the rectum, we 
may observe the paradox of a diarrhoea due to coprostasis above 
a stenosed segment. Hemorrhoids are also found in chronic 
diarrhoea, particularly in catarrh of the large intestine. In such 
cases the hemorrhoids may be caused by the tenesmus, hyperaemia, 
and perhaps also by the inflammation of the rectum and lower seg- 
ments of the large intestine. 

The external causes of hemorrhoids are tumours of the neigh- 
bouring organs which retard the rectal circulation. The simplest 
example of this is pregnancy, during which, according to Budin 18 , 
35 per cent of all hemorrhoidal cases develop. These disappear 
after the puerperium. Tumours of the uterine adnexa, retroflexion 
and tumours of the uterus, disease of the urethra and bladder, par- 
ticularly such as affect the contractility of the latter organs, may 
also produce hemorrhoids. 

Formerly disturbances of circulation (third cause) were regarded 
as the chief source of hemorrhoids. Even at present similar 
statements are found in almost all text-books of special pathology. 
Nothnagel 19 mentions the rarity of hemorrhoids in stasis of the 
portal system, and in diseases of the heart and lungs. He states 
that in cardiac insufficiency the pathological increase of pressure is 
spread over so large a vascular area that it would scarcely affect the 
hemorrhoidal plexus in the manner formerly assumed. My own 
experience also speaks against the theory of hemorrhoids from gen- 



5^8 DISEASES OF THE INTESTINES 

eral vascular congestion. Even if the two conditions coexisted it 
would still have to be demonstrated that the hemorrhoidal compli- 
cation was not due to the constipation present. 

Bouchard found hemorrhoids in 28 per cent of cases of chole- 
lithiasis. No comment on this is found in the classical monograph 
of Naunyn, and, as far as I know, this observation has not been 
confirmed. It does not agree with my own experience. That 
hemorrhoids may occasionally occur in cholelithiasis is not remark- 
able, for it is well known that a large proportion of these patients 
suffer from constipation. 

Heredity is often mentioned as a predisposing factor in hemor- 
rhoids, but in all probability there is really hereditary intestinal 
atony, a condition not at all infrequent. 

It has often been demonstrated that a sedentary life predisposes 
to hemorrhoids, but here again the hemorrhoids result from 
habitual constipation. 

Age and Sex. — That hemorrhoids is really a disease of advanced 
life follows both from the underlying conditions producing the dis- 
ease, and from the lessened elasticity of the vessels at this time of 
life. (I might mention that Lannelongue 20 reports a case of hemor- 
rhoids in a newly born infant.) It is quite striking (and my obser- 
vations upon numerous cases confirms this) that in the majority of 
instances hemorrhoids are more frequently found in men, whereas 
habitual constipation occurs oftenest in women. Besides this, the 
occupation of women is more restful and quiet than that of men. 
I can only explain this fact by the numerous venous plexuses in 
the female genitals, which, while not entirely preventing, certainly 
make the occurrence of varicose conditions very difficult. 

In my opinion, the oft-mentioned distinction between stout and 
thin anaemic hemorrhoidal patients will as little withstand scientific 
criticism as the distinction between stout and lean persons with dia- 
betes or constipation. This theory is a remnant of the old teaching, 
that hemorrhoids exert a beneficial influence upon the general sys- 
tem. It is true, as JSTothnagel says, that we find hemorrhoids much 
more rarely in stout individuals, but this is solely because the tense, 
firm connective tissue here present greatly retards the development 
of venous dilatation. Conversely, in cachectic individuals who do not 
suffer from severe constipation we may often observe hemorrhoids. 

Anatomically we differentiate between diffuse dilatation of the 
rectal veins and true hemorrhoidal nodules. The first generally form 
a visible rosette, consisting of dilated, often spirally twisted veins, 



DISEASES OF THE RECTUM 549 

under the skin or mucous membrane. Hemorrhoidal nodules, on 
the other hand, vary greatly in size, and are single or multiple. 
"When multiple, they surround the anus circularly or wreathlike, 
and are either sessile or pedunculated. Inflammatory adhesions 
may produce a confluence of the hemorrhoids, and, as a result, large, 
almost angiomatous masses are formed. The hemorrhoids may, 
however, atrophy, and become covered with epidermis. Their ori- 
ginal character can then only be recognised by their bluish colour, 
their consistency, and their characteristic arrangement. By throm- 
bosis and calcification of the veins so-called phleboliths may be 
formed. 

At present our views regarding the histological character of 
these varices differ. We shall not enter into a minute discussion 
of this subject, but only mention that Eeinbach a , who has recently 
carefully studied the histological structure of hemorrhoids, concludes 
that they are not varicose veins, but true benign tumours — i. e., 
angiomata. 

Hemorrhoids may conduce to rectal catarrh, with more or less 
marked mucous secretion (so-called "mucous hemorrhoids"). Fis- 
sures and excoriations occur quite frequently, and may lead to 
abscesses, fistulae, and (rarely) to very severe inflammation and peri- 
tonitis. 

Symptomatology 

The former view that hemorrhoids was a constitutional disease 
(even nowadays we speak of a " status hemorrhoidalis "), explains 
why the description of this disease was unnecessarily extensive. 
Many indefinite abdominal disturbances and circulatory and re- 
spiratory symptoms were attributed to hemorrhoids. Yenesection, 
which prevailed even to the middle of this century, was one of the 
consequences of these theories. 

At present hemorrhoids are viewed from a purely local stand- 
point ; we treat the hemorrhoidal nodule, and not the hemorrhoidal 
diathesis. We must not entirely relinquish the old theory of a gen- 
eral disturbance brought about by the " status hemorrhoidalis." We 
must admit that certain definite symptoms closely associated with 
altered blood pressure are produced by the hemorrhoidal varix; 
but many mild and (particularly in cachectic persons) severe cases 
run their course without symptoms. When present, the symptoms 
are generally limited to the diseased area, although, as already inti- 
mated, they may extend to other regions of the body. 

36 



550 DISEASES OF THE INTESTINES 

The local symptoms are constipation, a feeling of pressure and 
heaviness in the rectum, tenesmus, and itching and burning in the 
anal region. Defecation usually brings relief. In external hemor- 
rhoids there is also more or less discomfort in sitting, even upon a 
soft pillow, and in riding, bicycling, jumping, and gymnastics. 

These symptoms may be accompanied by hemorrhages, slight in 
amount or (rarely) sufficiently severe to cause the most profound 
anaemia or even death. The bleeding may recur periodically. 
Hemorrhages are often preceded by increased hemorrhoidal symp- 
toms — feeling of congestion, tenesmus, severe pains radiating to the 
bladder, etc. With the onset of the bleeding these symptoms dis- 
appear. 

Strangulation of protruding hemorrhoidal nodules constitutes 
one of the most painful complications. The masses which have 
been protruded from the anal fold by straining usually return 
easily, either spontaneously or by manipulation. They may, how- 
ever, remain prolapsed, and become swollen and inflamed ; an in- 
flammatory oedema then develops about the anus; the patients 
suffer unbearable pain, and, as in strangulated hernia, may collapse. 
If strangulation is not relieved, the nodules may become gangre- 
nous and necrotic, or a purulent inflammation with its serious 
sequences may result. 

In very old cases, in consequence of paresis of the sphincter, 
the nodules may prolapse in walking, bending, coughing, laughing, 
sneezing, etc. 

As already mentioned, inflammation of intra-rectal hemorrhoids 
may produce symptoms of acute proctitis — severe pain, repeated 
and increasing tenesmus, sphincteric spasm, etc., and occasionally 
fever. 

General disturbances are more apt to occur in chronic hemor- 
rhoidal disease. Besides chronic anaemia many patients suffer from 
abdominal fulness and pressure, necessitating the loosening of 
clothing. The passing of flatus affords temporary relief. There 
may also be severe pain in the back, increased by bending or other 
active motion. Some patients complain of sciatica, and resort unsuc- 
cessfully to bath treatment. Certain nervous symptoms are also 
present — a feeling of fulness in the head, dizziness, nausea, floating 
bodies before the eyes, etc. 

These symptoms may be considered neurasthenic, or, to be more 
modern, evidences of auto-intoxication, or perhaps as the result of 
habitual constipation. We must admit that there remain symptoms 



DISEASES OF THE RECTUM 55^ 

which can only be explained by changes in blood pressure in the 
vena cava and portal vein. If we remember that an accumulation 
of gas in the stomach or intestine not only gives rise to local dis- 
comfort, but also to general disturbances — pressure in the head, 
feelings of fear, palpitation, etc. — and if we recall the disturbances 
that occur in the beginning of menstruation, we must acknowledge 
the correctness of this view. The disappearance of these symp- 
toms, with the relief of the constipation is no proof that they 
depend upon that condition, for the hemorrhoidal affection is at the 
same time favourably influenced. 

Diagnosis and Differential Diagnosis 

In the great majority of cases the diagnosis is easy. Under no 
circumstances must it be based entirely upon the statements of the 
patient. Inspection of the anal region alone is not sufficient ; the 
rectum must always be included, and, in women, the genital organs. 
Treatment and prognosis are considerably influenced by the 
results of such examination. If internal hemorrhoids are sus- 
pected, they are best brought to view by having the patient strain 
strongly. It is best to first give an enema of warm salt water, 
and then to have the patient strain while sitting upon a chamber 
filled with warm water. If this does not succeed, a rectal specu- 
lum must be used. We should avoid the tubular speculum, which 
pushes the hemorrhoidal nodes aside, but, under the precaution men- 
tioned in the General Division, use the grooved instrument (page 
80). Erosions, ulcerations, proctitis, fissures, fistulee, etc., must also 
be looked for. 

The differential diagnosis is rarely difficult. Broad condylom- 
ata can only be mistaken for hemorrhoids when neither has before 
been seen. It may be more difficult to distinguish hemorrhoids 
from beginning carcinoma and ulcerations. Since hemorrhoids 
ulcerate very readily and leave deep lesions, error can only be 
avoided by careful consideration of all accompanying circumstances. 
The distinction between rectal polypi and hemorrhoids is readily 
made, although polypi may closely resemble thrombosed varices. 
In most instances careful and repeated examination will scarcely 
leave room for doubt. This is also true of the differentiation between 
prolapse of hemorrhoids and of the rectum. 



g£2 DISEASES OF THE INTESTINES 



Treatment 

Wherever possible, treatment should be directed toward the 
underlying cause. 

Since constipation is the most frequent etiological factor, we 
begin with its discussion. In referring to the regulations previ- 
ously described for the treatment of this condition, we have only to 
point out special peculiarities which exist in the constipation of 
these patients. Proper diet is of the greatest importance. We 
must distinguish, however, between hemorrhoids with and without 
bleeding, and between insignificant and profuse hemorrhages. 

The diet must be carefully regulated in patients with severe 
and habitual or with profuse and periodical hemorrhages. Spiced, 
sharp, piquant foods and drinks, as well as alcoholic beverages, 
particularly those of stronger concentration, must be avoided. 
Further dietetic restrictions are unnecessary. It is obvious that 
over-action, excessive walking, horseback riding, gymnastics, bicy- 
cling, etc., are to be forbidden. If there are no hemorrhages, or if 
they are insignificant, the diet should be that of chronic constipa- 
tion, with due consideration to the general health and nutritive 
condition of the patient. A so-called " bland diet," still advised in 
many text-books, is absolutely wrong. The favourable influences 
of diet may be further increased by active and passive motion, 
rowing, room gymnastics, billiard playing, bowling, tennis, Swedish 
movements, and massage. Owing to the continual local friction 
and increased circulatory disturbances, horseback riding, and prob- 
ably also bicycling, act unfavourably. 

If diet alone does not produce sufficient evacuations, it must be 
aided by appropriate laxatives. For this purpose, the sulphur 
preparations (flowers of sulphur, one teaspoonful t. i. d), and laxa- 
tives containing them (compound licorice powder, one teaspoonful 
morning and evening), have been long and deservedly valued. 
They operate in accordance with the tenets of the old school : 
" Cito, tuio et jucundeP Whenever a change of remedies is indi- 
cated, the other laxatives mentioned in the chapter on Habitual 
Constipation may be used, though the above preparations will gen- 
erally suffice for a long time. The drastic cathartics are said to be 
harmful in the treatment of this constipation. Recently they have 
been added to the causative factors of hemorrhoids (Rosenheim 22 ). 
It is certainly an exaggeration to regard drastics as productive of 



DISEASES OF THE RECTUM 553 

hemorrhoids, but in some instances it does no harm if the physician 
supports such theories. 

Enemata are rarely indicated in hemorrhoids, for manipulations 
with the usual rectal tubes are apt to irritate, lacerate, and inflame 
the hemorrhoidal nodules. Chemical agents, including oil, added 
to enemata, also act harmfully. This applies particularly to glyc- 
erin, which causes severe pain and tenesmus. 

Almost all text-books advise avoidance of sexual excesses, and 
claim they may produce hemorrhoids. This statement is true, in so 
far as these should be avoided by healthy as well as diseased indi- 
viduals. That sexual excesses are especially harmful to those with 
hemorrhoids seems to me to be based on mere speculation, and not 
upon scientific experience. I cannot comprehend how a temporary 
congestion of the genitals can produce the serious results described. 

The use of baths and mineral waters must be briefly touched 
upon. Only those watering places which contain both appropriate 
baths and appropriate laxatives (sodium chloride or sulphate) come 
into consideration. First and foremost are the cold saline springs 
of Kissingen and Homburg,. then the sodium sulphate waters of 
Marienbad, Tarasp, Elster (" Salt Spring "), Franzenbad (" Salt 
Spring "), Rohitsch, and others.* In some watering resorts (Elster, 
Marienbad, Franzenbad) persons ansemic from loss of blood may 
also use an iron spring. In recent times — even medicine follows 
fashion, as proved by the yearly increasing number of people who 
visit these springs — great health-giving properties have been attrib- 
uted to mineral waters. Convinced by numerous excellent- results 
from a sojourn at these springs, many patients visit them on their 
own account and recommend their use to others. As physicians, 
we must as far as possible consider the wishes of our patients, but 
we should also know the limits of the action of these cures, and not 
promise greater results than actually occur. We must admit that 
these springs generally affect the hemorrhoidal disease very favour- 
ably. This is quite natural, for the patients find themselves in 
almost ideal surroundings for the treatment of their disease. The 
use of aperient waters, the necessary exercise, the appropriate diet, 
and, not the least, the hygiene of the anal region secured by numer- 
ous baths, all combine to produce a condition never, even under the 
best of circumstances, obtainable at home. But with this, however, 

* [For corresponding springs and wells in the United States, see pp. 161 and 
162.— Tr.] 



554 DISEASES OF THE INTESTINES 

balneotherapy finds its limitations. As soon as the patients resume 
their usual habits of life the old condition returns, and the dearly 
bought sojourn at the springs loses its magic. It is therefore the 
duty of the physician to explain to the patient what benefit he may 
expect from his course of waters, so that gain in health and neces- 
sary sacrifice of time and money may be properly proportioned. 
Permanent good often results from repeated yearly visits to the 
baths and springs, but this cannot be determined beforehand. 

Of the symptomatic remedies for external and mixed hemor- 
rhoids, the first is the toilet of the anus. The patient is to keep the 
anal region absolutely clean. After every act of defecation, this 
region and the hemorrhoids themselves are to be carefully washed 
with absorbent cotton (not sponges) dipped in a cold three-per-cent 
boric-acid solution, or, what I especially recommend, a tannin solu- 
tion (teaspoonful to a quart of water). Cold antiseptic or astrin- 
gent washings are very agreeable to the patient, and are to be re- 
peatedly used. We should, however, always study our patients 
before giving directions. I know from experience that in neuras- 
thenics such regulations may lead to quite unpleasant consequences. 
The patients examine their anus all day long by means of mirrors 
and reflectors, just as tongue hypochondriacs do their tongues. 

The most important complications of hemorrhoids are severe 
periodic or marked chronic hemorrhages. In milder bleeding treat- 
ment is scarcely necessary. In severe hemorrhage it is best not to 
delay too long with ineffectual remedies such as the introduction of 
ice, injections of tannin or liquor ferri into the rectum. By means 
of a speculum we tampon the rectum with gauze or cotton dipped 
in liquor ferri or ferripyrin solution. As in uterine hemorrhages, 
hot irrigations (35° to 40° C.) have been recommended by several 
authors (Sandowski and others). If these measures do not control 
the bleeding, the bleeding vessels or tissue must be sought for and 
tied off.* 

In continuous hemorrhages, particularly where there is angemia 
and general weakness, I would recommend witch hazel. I use the 

* [Firm packing of the bleeding area with dry gauze (if necessary under general 
anaesthesia) is the simplest and surest of the non-operative means of arresting 
hemorrhage. The hard clot and the dirty, slowly healing slough after the applica- 
tion of the liquor ferri, make its employment undesirable. I have seen rapid and 
permanent arrest of rectal hemorrhage follow the direct application of cotton 
swabs soaked with fifty-per-cent antipyrin solution to the bleeding surface. Per- 
haps, too, the local use of solutions of suprarenal extract would be effectual. Ab- 
solute rest is of course essential to arrest of hemorrhage. — Tr.] 



DISEASES OF THE RECTUM 555 

fluid extract exclusively in teaspoonful doses three times daily. I 
have had no experience with the dry extract " hamamelin " (dose, 
0.05 to 0.06 gram) recommended by Soulier 23 for the same purpose. 
Since the different preparations in the market vary in strength, we 
should use a reliable one. After an extended experience I do not 
• at all doubt the action of hamamelis in hemorrhoidal hemorrhage. 
The remedy may be taken for weeks and months without producing 
untoward symptoms. In continuous hemorrhages I have the pa- 
tients take the drug regularly six to eight weeks. 

Ergotin, Hydrastis canadensis, liq. pot. arsenitis, glycerin, and 
other remedies have been recommended in hemorrhages of this 
character, but no definite proof of their favourable action exists. 
Personally, I have had no experience with them. 

Keposition is the chief measure in strangulation of varix nodules. 
This is best carried out with the patient lying on his side, and the 
hemorrhoidal mass and the parts about freely smeared with an oint- 
ment containing cocain, eucain, or opium, or with olive oil. Gentle 
pressure must be made. Narcosis, when possible, is preferable. 
Schleich's local anaesthesia, however, is even better. Leeches ap- 
plied to the anus (but not to the varices) are very useful in reposi- 
tion. After an abundant hemorrhage the hemorrhoids are easily 
replaced. When gangrene has occurred the nodules should be 
dusted with an antiseptic powder (iodoform, airol, xeroform, etc.).* 

Besides these important complications, there are inflammatory 
swellings and excoriations of external and internal hemorrhoids. 
In the former, anaesthetic suppositories (cocain, eucain, opium, 
belladonna, and morphin) are generally useful. Unna, Kosso- 
budskji 34 , and Macdonald 25 recommend the following suppositories : 

5 Chrysarobin 0.08 

Iodoform 0.02 

Ext. bellad 0.01 

Butyr. cacao 2.00 

D. t. dos. No. x. 

S. : Apply one suppository two to three times daily. 



* [If the patient refuse anaesthesia or operation, and reposition otherwise is im- 
possible, rest, local application of ice, and free inunctions with gallic ointment, 
with opium, cocain, belladonna, etc., are in order. Under these, reduction in size 
often follows and reposition is then possible. It would be interesting to try the 
suprarenal extract or adrenalin in these conditions. Occasionally gangrene and a 
spontaneous cure occur. — Tr.] 



556 DISEASES OF THE INTESTINES 

It would be interesting to know which of these three remedies, 
chrysarobin, iodoform, or belladonna, is the effectual one. 

As may be seen from their composition, styptic properties are 
attributed to these suppositories. For a like purpose, Rosenheim * 
recommends the injection of a very weak solution of nitrate of sil- 
ver (one gram of a one-half -per-cent to one-per-cent solution) into 
the rectum by means of a specially devised syringe. Anaesthetic 
ointments may also be applied with the collapsable tube, previously 
described. 

In external hemorrhoids the various ointments again come into 
consideration. Chrysarobin enjoys a special reputation. The oint- 
ment recommended by Kossobudskji is as follows : 

5 Chrysarobin 0.8 

Iodoform 0.3 

Ext. bellad 0.6 

Yaselini 15.0 

D. S. : To be freely applied several times daily. 

We will not enumerate the numerous other salves which prob- 
ably act only through the anaesthetic drugs they contain. Preis- 
mann 26 praises the action of external applications of iodin-glycerin 
very highly, and gives the following : 

^ Kali iodati 2.00 

Iodi puri 0.20 

Glycerini 35.00 

Later in the disease he increases the strength of the applica- 
tion, thus : 

^ Kali iodati 5.00 

Iodi puri 1.00 

Glycerini 40.00 

Esmarch's rectal support is also to be recommended in prolapsed 
hemorrhoids (see Fig. 46). 

We must distinguish between " bloodless " and " bloody " sur- 
gical measures. The former include stretching of the sphincter, 
particularly recommended by French authorities (Yerneuil and 
others). It may be carried out in one or in several sittings by 
forced dilatation with fenestrated speculum, the blades being sepa- 
rated by a special mechanism. The same result can be more sirn- 

* Loc. cit., p. 236. 



DISEASES OF THE RECTUM 557 

ply accomplished by passing two fingers into the rectum after pre- 
vious introduction of a grooved speculum and eversion of the rec- 
tum. The second bloodless method, used and recommended more 
especially in England and America, is the fixed or elastic ligature 
(von Dittel). As far as I know, this procedure is but little used in 
Germany. Destruction of the nodules with fuming nitric or carbolic 
acid is also practiced ; the skin of the anal region and the peri- 
neum is protected from the action of the acid by a thick coating of 
vaselin. 

In 1887, Lange 27 , of ~New York, recommended local injections 
of carbolic acid and glycerin, in concentration of 1 : 5 to 1 : 2. In 
numerous cases, even of large nodules, this method has proved suc- 
cessful in my hands. I usually proceed as follows : 

The patient is told to press out the nodules. For this purpose 
it is best to give him a warm enema beforehand, or to have him 
sit on a bed-chamber filled with hot water. The rectum and the 
anus are then carefully cleansed with a one-half -per-cent lysol solu- 
tion. The skin about the anus is smeared with borated vaselin. 
As an injection I use fifty-per-cent carbolic-acid glycerin, employ- 
ing an accurately graduated syringe. The needle is introduced at 
the border of each nodule, about three drops injected into each, 
and the needle is allowed to remain in situ for a few minutes. 
After it has been withdrawn and the parts again cleansed, the other 
nodules are successively treated in the same manner. If possible, 
the prolapsed nodules are replaced, a large cotton pad and T-bandage 
applied, and, to produce constipation, fifteen drops of the tincture of 
opium and a temporary bland diet given. Eest in bed from two to 
three days. Castor oil on the third day. Limited activity for sev- 
eral days. 

In only one of my cases did acute inflammation follow ; under 
appropriate treatment the inflammation soon disappeared. All the 
cures resulted without much pain. This operation does not guard 
against relapses, but it has the great advantages of simplicity and 
lack of danger.* 

The " bloody " methods of operation seek destruction of the 
hemorrhoids by the production of scar tissue by means of either the 
actual or thermo-cautery [Paquelin], the galvano-caustic loop (von 
Bardeleben), or by extirpation of the nodules and subsequent suture 

*Roux 28 very appropriately says of this method: "Compared to the bloody 
operations it has only one disadvantage : it is no longer an art to rapidly and care- 
fully operate hemorrhoids." 



558 DISEASES OF THE INTESTINES 

(Whitehead's operation). These are the operations generally per- 
formed in Germany ; they will be found described in surgical text- 
books. 

LITERATURE 

1. Jullien. Beitrage zur Dermatologie u. Syphilis. Festschrift fur G. Lewin, 

1895. 

2. Th. Baer. Deutsche rned. Wochenschr., 1896, No. 8, and 1897, No. 51 

u. 52. 

3. Bushe. Cited by von Esmarch, Die Krankheiten d. Mastdarms u. d. 

Afters. Stuttgart, 1887, S. 72. 

4. Quenu et Hartmann. Chirurgie du Rectum. Paris, 1895, p. 188. 

5. Allingham. The Diagnosis and Treatment of Diseases of the Rectum, 

p. 269, sixth edition, 1896. 

6. Van der Willigen. Neederl.-Tijdschr. v. Geneeskunde, 1893, i, No. 17. 

Cited from the Centralbl. fur Gynacologie, 1895, S. 481. 

7. Conitzer. Munch, med. Wochenschr., 1899, No. 3. 

8. Rieder. Archiv f. klin. Chirurgie, 1897, Bd. lv, S. 730. 

9. Nickel. Virchow's Archiv, Bd. cxvii, S. 279. 

10. Polchen. Ibid., S, 189. 

11. Virchow. Die krankhaften Geschwulste, 1864-1865, Bd. ii, S. 416. 

12. Alclerhot. Beitrage zur Kenntniss der Rectumsyphilis. Diss.-Inaug. 

Berlin, 1896. 

13. Thiem. Verhandl. der deutschen Gesellschaft fur Chirurgie, 1893, Bd. i, 

S. 49. 

14. Sonnenburg. Ibid., 1897. 

15. Rotter. Archiv f. klin. Chirurgie, Bd. lviii, S. 334. 

16. Schede. Verhandl. d. deutschen Gesellschaft f. Chirurgie, 1895. 

17. Bokai. Krankheiten des Mastdarms u. des Afters. Gerhardt's Handbuch 

der Kinderkrankheiten, vi, 2te Abth. 

18. Budin. Cited from Galliard, Maladies de Tintestin. Traite de Medecine, 

t. iv, p. 698. 

19. Nothnagel. Darmkrankheiten, S. 469. 

20. Lannelongue. Cited by Galliard (see reference 18). 

21. Reinbach. Beitrage zur klin. Chirurgie, 1897, Bd. xix, H. 1. 

22. Rosenheim. Die Pathologie u. Therapie d. Krankheiten des Darmes, 

S. 219. 

23. Soulier. Cited from Mathieu. Therapeutique des maladies de l'intestin, 

second edition, p. 91. 

24. Kossobudskji. Cited from the Centralbl. f. Chirurgie, 1889. 

25. Macdonald. Cited from the Wiener med. Presse, 1892, S. 1886. 

26. Preismann. Weiner med. Presse, 1891, No. 22. 

27. Lange. Verhandl. der deutschen Gesellschaft f. Chirurgie, 1887. Cited 

from the Centralbl. f. Chirurgie, 1887. 

28. Roux. Therapeutische Monatsh., Marz, 1895. 



CHAPTEB XXIV 

NERVOUS DISEASES OF THE INTESTINES 

Preliminary Remarks. — In the General Division ('page 31) we 
have given a brief and incomplete description of intestinal innerva- 
tion. From this it is seen with what complicated conditions we 
must deal in describing the pathology of intestinal neuroses. 

The few anatomico-pathological investigations of Jiirgens 1 , 
Blasekko 2 , Sasaki 3 , Schleimpflug 4 . and Emminghaus 5 point the 
way to future investigators ; in themselves they are not sufficient 
for clinical purposes. 

The uncertainty of the study of intestinal neuroses is further in- 
creased by the unstable transition between organic intestinal disease 
and the so-called neuroses. Just as cystitis may develop from vesi- 
cal paralysis of spinal origin, so organic changes in the intestinal 
mucous membrane may arise from disturbances of intestinal inner- 
vation. At certain stages we can recognise changes, but not their 
origin. Disturbances of intestinal innervation probably do not fol- 
low one course, but secretory-motor and vaso-motor disturbances 
combine. 

Under conditions so little understood, our only resource is clini- 
cal observation and experience. 

Like gastric neuroses, intestinal neuroses may be divided into 
motor, sensory, and secretory. There is also a mixed or " com- 
plex" form of intestinal neurosis, which appears as general intes- 
tinal neurasthenia. 

1. Motor Neuroses 

(a) Enterospasm and Proctospasm 

While spastic conditions of the bowel are most frequent and 
prominent in organic intestinal disease (particularly stenosis ), entero- 
spasm is very seldom observed as a purely functional neurosis. 

559 



560 DISEASES OF THE INTESTINES 

.Nothnagel 6 denies its existence entirely. This seems to me 
somewhat farfetched, although experienced physicians must admit 
the rarity of primary, spastic intestinal contraction. Few cases have 
been reported, and these (including the one of Talma cited by 
ISTothnagel *) are not entirely free from objections. Proctosjpasm is 
usually secondary to local affections of the rectum or of the pelvic 
organs. It is met with as a functional condition (occasionally com- 
bined with anal crises) in tabes dorsalis, and as a symptom of gen- 
eral hysteria and neurasthenia. 

Symptomatology and Diagnosis 

The principal symptoms of enterospasm are painful intestinal 
contractions which the patient feels, and which are accompanied 
by rumbling and borborygmi, and by the passage of fragmentary 
scybalse, with marked rectal tenesmus. 

These symptoms generally occur at intervals, and are often 
started or increased by excitement. The following is an example 
of enterospasm of nervous origin : 

Miss H., sixty years, of age, has for many years suffered from the following 
attacks : Every four to eight days, without apparent cause, sudden severe pain 
is felt in the umbilical region. At the height of the attack there is an urgent 
desire to defecate. Three to five times a day she passes many small, thin faecal 
masses. Each act of defecation is followed by one or two hours of ease. 

During these attacks (which often last a whole day) the patient is confined 
to her room. The abdomen is frequently distended. Except for mild consti- 
pation, the patient is subjectively well. She ascribes her affection to overworry. 
The first attacks began twenty-five years ago. Besides slight hemorrhoids, this 
very robust and well-nourished woman presents no objective symptoms. 

In cases like this the diagnosis is readily made, but where the 
etiology is less clear it may be very difficult to distinguish between 
this affection and organic stenosis. The following points are impor- 
tant : the long duration of the affection, the good general condition, 
normal health in the interval between attacks, and the presence of 
neurasthenic or hysterical stigmata. 

The symptoms of proctospasm consist of severe periodical, some- 
times almost unbearable pain in the rectum, accompanied by sphinc- 
teric contraction. 

The following cases will illustrate and explain the clinical pic- 
ture of the disease : 



Loc. cit., p. 463. 



NERVOUS DISEASES OF THE INTESTINES 561 

I. (Observation of Peyer 7 .) Sexual neurasthenic, aged fifty, suffers from 
various severe neuralgias, particularly of the testicle. His proctospasm shows 
itself at first as a marked, painful tenesmus of the rectum, necessitating an im- 
mediate attempt at defecation, but neither stool nor wind passes. With this 
tenesmus there is a very severe spasm of the sphincter, so that the patient can- 
not force even the narrow canula of an irrigating syringe into his rectum. Af- 
ter some time the pain leaves suddenly and radiates to the bladder or testicle. 

II. (Personal observation.) Mr. K., merchant of Prague, aged fifty-two, 
good family history, had a mild attack of syphilis six years ago. Later, articu- 
lar rheumatism, which his physician ascribed to the syphilis. Irregular stool 
during the confinement to bed necessitated by the rheumatism. Though he gen- 
erally sleeps well, and has a good appetite, he has become very nervous through 
much overwork. There is constipation, and occasionally mild tenesmus. 
When tenesmus is severe, diarrhoea ensues ; normal, cylindrical stool is very 
rare. 

During the last few years he suffers from anal spasms every two or three 
days, and more recently every three to five days. These generally come on at 
night. The patient is suddenly awakened by severe pain, as if the sphincter 
ani were spasmodically drawing itself together. The finger can be introduced 
only with great difficulty. The spasm may be controlled by the successive 
introduction of the larger fingers. In a few minutes the entire attack ceases. 
The proctospasm is generally preceded by constipation, and never occurs after 
satisfactory defecation. 

In the interval between attacks the calibre of the rectum is normal. No 
symptoms of tabes.* 

The diagnosis of proctospasm is not difficult. In order to estab- 
lish the nervous character of the disease it is always necessary to 
make a rectal or vaginal examination. 

Treatment 

Where appreciable lesions of the rectum or genitals exist, or 
where the symptoms are produced by spinal disease, appropriate 
measures must be applied. In purely functional entero- and procto- 
spasm it will be necessary to treat the underlying nervous basis of 
the disease. For this purpose cold hydrotherapeutic measures, ene- 
mata (perhaps with the rectal cooler), mild galvanization of the rec- 
tum and abdomen, and systematic passing of elastic bougies are best. 
The attack may be checked by bromids, or by opium, morphin, 
belladonna, codein, and cocain, internally or in suppositories. Con- 
stipation, if present, should be treated dietetically, with or without 
the addition of mild purgatives and enemata. 

* We must always remember the possibility of this being an initial symptom of 
tabes, which, analogous to gastric crises, may antedate the ataxia by many years. 



562 DISEASES OF THE INTESTINES 

(b) Peristaltic Restlessness {Tormina Intestinorum Nervosa) 

Kussmaul 8 , in 1878, was the first to call attention to the occur- 
rence of visible peristalsis of the stomach and intestine in neuro- 
pathic individuals. These contractions may affect stomach and 
intestines together or each separately. They occur in paroxysms, 
particularly after nervous excitement. They are usually observed 
in women with flabby abdominal walls and enteroptosis. Peyer 7 has 
observed several cases in male sexual neurasthenics. 

Symptomatology and Diagnosis 

The chief symptoms are a feeling of movement and of drawing 
together in the abdomen, which may increase to spasmodic pain. 
In marked cases there may be simultaneous rumbling sounds. These 
attacks are independent of the time of food ingestion, but may be 
visibly increased by certain agents — carbonated beverages, laxa- 
tives, etc. They frequently occur at night, and deprive the patient 
of sleep. 

On inspection, the lively peristaltic wavelike motion of the 
intestine is usually immediately apparent. Where the picture is 
not well defined, hyperperistalsis may be induced by abdominal 
friction, pouring ether upon the abdomen, faradism, and distention 
of the stomach or intestine with air or carbonic acid. The peristal- 
sis mainly involves the small intestine, but, as shown by the case 
described below, the large intestine may also be affected. JSoth- 
nagel 6 maintains that evacuations always accompany the latter 
condition. In my case this was not so ; the patient always had 
normal stool. 

The attacks vary considerably in intensity and duration. In the 
same individual I have sometimes seen mild peristalsis last for hours, 
and violent actions decrease after a few minutes. 

In my work on Diseases of the Stomach (Part II, third edition, 
p. 236) I have described a case of this kind. I demonstrated a 
second much more typical patient at the Congress for Internal 
Medicine 9 . As the latter case is very interesting I repeat it here : 

Pauline R, sixty years old, peasant's wife, has had considerable trouble 
and worry throughout her life. Her father, a teacher, suffered from nervous- 
ness during the last few years of his life, and committed suicide in his fifty- 
second year. Patient has a brother who is quite well. No other sickness in 
the family. 

Patient herself, when a young girl, was always anaemic, and had "liver 



NERVOUS DISEASES OF THE INTESTINES 553 

trouble,'' but was never confined to bed, and never had jaundice. Present ill- 
ness began about eight years ago, when, after passing through a severe illness 
and after the death of her husband, she spent many weeks in mental suffering. 
Her symptoms then consisted of an occasional uaveWke motion in the abdomen, 
ichich disappeared whenever she felt contented or happy. 

The death of her only son aggravated her condition. Since then (three 
years) her condition has remained about the same. She is sometimes entirely 
well for weeks and months, then, generally after some psychic disturbance, she 
suffers for days or weeks. Since March of this year the symptoms are almost 
continuous; this she ascribes to the severe illness of her son-in-law. 

She complains of a feeling as of a dead weight in the abdomen and a wave- 
like sensation, which occur usually at night. The attacks are independent of 
work, and are frequently relieved by eating. Appetite good; bowels regular. 
Patient does not otherwise feel ill. Has had five children ; no miscarriages. 

Status prcesens. — Frail woman, good colour, poorly developed muscular sys- 
tem and fat. Pupils react well to light, but not so well to accommodation. 
Triceps and patellar reflexes cannot be elicited. Skin reflexes markedly dimin- 
ished. Lungs and heart normal. Abdomen is hemispherically distended, the 
greatest prominence appearing below the umbilicus. "When the patient raises 
the upper portion of her body the intestines press forward through a broad dias- 
tasis of the recti muscles, which reaches from the umbilicus to the symphysis. 
Abdominal walls are thin and flabby. 

Liver: Upper border begins at the seventh rib in the mammary line. As 
determined by palpation and percussion, the lower border of the liver corre- 
sponds to a line beginning two fingerbreadths above the right anterior inferior 
spine of the ilium, passing through the umbilicus, and reaching the eighth left 
costal cartilage. Above this line there is uniform dulness. The sharp border 
of the liver may be plainly felt in the right half of this line, less so in the left 
half. The spleen is slightly movable, and its border may be felt in the left 
hypochondrium. 

Kidneys are palpable. 

As determined by palpation of an introduced sound, distention, and trans- 
illumination in the fasting condition, the greater curvature of the stomach 
extends a handbreadth below the umbilicus. During fasting the stomach is 
empty. Test breakfast shows normal gastric functions. The urine contains 
no albumin, sugar, or indican. Microscopical and macroscopical examination 
of the stools shows no changes. 

Through the thin, flabby abdominal walls one can plainly see the peri- 
staltic movements (Fig. 47). Three types may be distinguished; they vary in 
position, form, and course. 

During rest, one sees two or three parallel sausage-shaped protuberances 
lying quite closely together. These periods of rest last but a very short time. 
Soon each protuberance is seen to contract at one end. The wave of contraction 
passes along the entire segment, while behind it the protuberance again reforms. 
The whole action is slow and vermicular. There is a continuous alternation of 
contraction and protuberance, and, following the simile of Xothnagel, the sur- 
face of the abdomen may be compared to that of a bag filled with potatoes. 

In the left side of the abdomen, from the free border of the ribs to about 



564 



DISEASES OF THE INTESTINES 



the anterior superior iliac spine, five — occasionally six — parallel swellings, each 
about the thickness of a stout lead pencil, may be seen. They are somewhat 
farther apart than the sausage-shaped tumours before described, and approxi- 
mately one half the length of the latter (about 4 to 5 centimetres). Several 
of these swellings disappear and reappear one after the other, thus giving 
the impression as of the whole mass suddenly springing forward ("harmonica 
motion "), Seemingly independent of the motions just described, a line of 
shadow passes about midway between these tumours, oscillating from left to 
right and vice versa. 

In the epigastrium a semicircular arching may be seen, the lower border 
corresponding exactly to the greater curvature of the stomach. Along this 
border a deep contraction passes from left to right, and is immediately suc- 








Fig. 47. 



-Pekistaltic Kestlessness of the Small Intestines and Descending Colon. 
(Original observation.) 



ceeded by a protrusion. One or two fingerbreadths below the liver the con- 
traction continues somewhat longer, so that we see two protrusions separated 
by a depression ; from this point the contraction again takes place more ener- 
getically, till the line of liver dulness is reached. The series then begins anew 
and continues uninterruptedly. The direction of motion is always from left to 
right. Each series lasts from fifteen to eighteen seconds. 

The patient does not feel these motions. Throughout the examinations she 
has pain only when the peristalsis becomes severe. A pulsation can also be seen; 
it may be mistaken for peristalsis. The pulsation evidently originates in the 



NERVOUS DISEASES OF THE INTESTINES 565 

great arterial trunks, and is transmitted through the flabby abdominal walls- 
It can be seen, and not felt, and is synchronous with the radial pulse. 

These peristaltic movements may be increased to a slight extent by faradi- 
zation, friction, and cooling the abdomen. 

The diagnosis of the condition is not difficult. We must always 
consider the possibility of intestinal stenosis or partial adhesions. 
Several years ago I observed a large, fixed umbilical hernia com- 
plicated by hyperperistalsis. The condition of the general nervous 
system, the alternate disappearance and reappearance of the peri- 
staltic movements, and its dependence upon excitement, are useful 
diagnostic facts. 

Treatment 

We must first attempt to strengthen the general nervous sys- 
tem through appropriate climatic and hydrotherapeutic measures. 
Kussmaul has achieved good results from the intragastric and ex- 
ternal use of the faradic current. 

Internally, we may give the alkaline bromid salts, narcotics, and 
perhaps also antipyretics (antipyrin, phenacetin, lactophenin, etc.). 
In one case I saw good results from codein and belladonna. Rosen- 
heim 10 recommends chloral hydrate (1 gram, evenings, in gruel). 

In the case described the attacks ceased when the patient was 
admitted to my private clinic for closer observation. Bodily and 
mental rest and appropriate nursing evidently contributed consider- 
ably to this favourable result. 

(c) Paresis (Atony) and Paralysis of the Intestines 

Paresis or atony of the intestines (" intestinal insufficiency," 
O. Rosenbach) is a functional debility of the intestinal muscular 
system ; paralysis is an absolute loss of the motor power of the 
intestines. Both conditions affect the large bowel only. Pareses 
of the muscle of the small bowel are unknown. In the chapter on 
Intestinal Strictures and Intestinal Obstruction we have described 
paralytic conditions of mechanical origin. In what follows we shall 
discuss only their functional phases. 

(1) Atohy of the Large Intestine 

This is closely related to and as frequent as constipation. All 
the factors which produce constipation may in time produce fiabbi- 
ness or muscular fatigue of the bowel, and, as a result, partial or 
general distention, or even actual dilatation of the intestine. Con- 

37 



566 DISEASES OF THE INTESTINES 

stipation is here the primary factor. Much more difficult is the 
determination of other conditions which produce primary paresis 
of the nervous muscular apparatus. By the previously described 
experiments of Emminghaus, it was shown for the first time that 
degenerative processes of the splanchnic nerve may produce consti- 
pation ; this constipation must be considered as an example of 
neuropathic intestinal atony. The artificial or toxic intestinal 
pareses following the use of opium, morphin, and belladonna must 
be placed in the same category. In a case under my own observa- 
tion, a woman who within a few weeks had taken more than one 
kilogram [2.2 pounds] of bismuth for symptoms resembling gastric 
ulcer, there developed most marked intestinal paresis and dilatation. 
It is well known that individuals who suffer from neuroses and 
psychic disturbances (neurasthenia, melancholia, hysteria, hypochon- 
dria, etc.) frequently develop paretic or subparetic conditions of 
the intestinal muscular apparatus. Thus, in persons predisposed to 
habitual constipation, I have occasionally observed acute intestinal 
paralyses from sudden fear, anger, or other excitement. We may 
explain these phenomena by reflex irritation of the nerves that in- 
hibit intestinal peristalsis (splanchnics). In view of analogous con- 
ditions in the stomach, we must also admit that traumatism and 
shock may produce an inhibitory action upon the motor apparatus 
of the large intestine. Congenital atony of the intestine has also 
been observed. Intestinal paresis may result from the continuous 
use of large rectal enemata. 

Clinical observation has led to the differentiation between gen- 
eral and partial atony. In a series of articles Federn n has called 
attention to the latter condition. According to this author, partial 
atony plays a large part in general pathology. He finds this condi- 
tion not alone in intestinal diseases, but also in arterio-sclerosis, car- 
diac asthma, pulmonary tuberculosis, neurasthenia and hysteria, and 
Basedow's disease. Federn even states that partial intestinal atony 
is connected with the development of the last-named disease. He 
maintains that the diagnosis of partial atony can be made from the 
strikingly pungent smell of the stools, and from the fact that gentle 
percussion of the intestines elicits dulness over some areas, while 
deep percussion of the same areas elicits a tympanitic percussion 
note. 

It needs no special demonstration to prove how little defined 
and characteristic are the symptoms described by Federn. Never- 
theless, there is a grain of truth in Federn's observations, a truth 



NERVOUS DISEASES OF THE INTESTINES 557 

of which experienced physicians have not been as ignorant as this 
author would have us believe. At several places along the intes- 
tines, as the result of faecal stagnation, partial ballooning may de- 
velop, and despite the presence of diarrhoea (stercoraceous diar- 
rhoeas), faecal stagnation may exist. As is well known, the sites of 
predilection for faecal accumulations are the caecum, the hepatic and 
splenic flexures, the sigmoid flexure, and the ampulla of the rectum. 
M. Herz 12 has recently directed attention to a further type of 
intestinal insufficiency — that of the ileo-caecal valve. Normally, the 
large intestine is shut off from the ileum by this valve. From in- 
flammation or by flattening of its lower fold there may result a 
relative insufficiency of the valve, as shown by tympanites, consti- 
pation, flatulency, and neurasthenic and other nervous symptoms. 

Symptomatology and Diagnosis 

These have in greater part been described in the chapters on 
Habitual Constipation and Chronic Enteritis. Atony is frequently 
associated with the latter condition. 

Atony is most easily demonstrated by the method described in 
the General Division of this work (page 74). It consists in the 
injection of measured quantities of water per rectum and the elicit- 
ing of splashing sounds in the corresponding segments of the large 
intestine. Upon distending with air, we find that the amount re- 
quired is far above the normal ; this also speaks for abnormal flab- 
biness of the intestine. Herz believes that proof of ileo-caecal 
insufficiency is demonstrated when gas under pressure can be forced 
from the caecum into the ileum. The changes in the percussion 
note are best obtained by percussing with the edge of the finger- 
nail of one hand upon the nail surface of the other. 

The clinical aspect of diffuse atony is so characteristic, that 
its diagnosis will rarely be difficult. In every case, however, 
we should think of the possibility of an underlying mechanical 
cause. 

As long as we have no more definite data than that obtained 
from percussion, we shall not be able to diagnose partial intestinal 
atony. 

Treatment 

This is identical with that described under Habitual Constipa- 
tion and Chronic Enteritis (q. v.). It is unnecessary to repeat the 
detailed regulations there given. In ileo-caecal insufficiency, Herz 



568 DISEASES OF THE INTESTINES 

recommends massage of the large bowel. In partial atony, besides 
massage, Federn advises faradization of the large intestine. 

(2) Paresis and Paralysis of the Rectum 

In describing paralytic ileus (page 403) we also discussed paral- 
ysis of the large intestine. It still remains to describe paresis of 
the rectum. 

Chronic paresis of the rectum generally results from local rectal 
affections (prolapse, tumours, proctitis, hemorrhoids, etc.), but occurs 
also as a symptom of some spinal and cerebral lesions (locomotor 
ataxia, progressive paralysis, myelitis, etc.). Straining during defe- 
cation and urination in prostatic hypertrophy and stricture of the 
urethra may likewise produce rectal paralysis. As a purely neurotic 
affection this condition is extremely rare. I have once seen it in 
a boy of nine years who was convalescing from diphtheria. 

Several degrees of rectal paralysis are met with. In mild cases 
the rectum is only relatively incontinent ; in the severe it is abso- 
lutely so. 

Symptomatology and Diagnosis 

The main symptom is loss of voluntary control of evacuations. 
In mild cases the sphincter is incontinent only when there is diar- 
rhoea; in the severe, formed stools are also involuntarily passed. 
Active movements of the body, slight straining of the abdominal 
muscles, coughing, laughing, and sneezing may cause involuntary 
evacuations and thus distress the patient. 

The diagnosis can at once be made by digital examination of 
the rectum. The question of etiology is more difficult. We must 
search for not only disease of the rectum and of intestinal segments 
higher up, but also for spinal disease. As shown by the following 
history, it may not be easy to arrive at the proper explanation of 
some of these cases. 

F. S. , aged twenty-two years, book gilder, has lost control over his stools 
for the last two years. As soon as there is a desire to defecate, no matter 
whether the stools be solid or fluid, an involuntary evacuation immediately fol- 
lows. The patient also complains about urination ; he must wait some little 
time before the urine begins to flow. The act of urination is normal and does 
not indicate stricture. Denies gonorrhoea and other sexual diseases. 

Patient works considerably with metallic dust which does not contain lead. 

Status Prcesens. — Healthy-looking young man; internal organs normal. 
Anus very flabby, readily admitting two fingers. Proctoscopy shows nothing 
special. Patellar reflexes markedly increased; no disturbance of sensibility. 



NERVOUS DISEASES OF THE INTESTINES 569 

The diagnosis of beginning spinal lesion was made. This was concurred in by 
Professor Oppenheim, who, in view of the intact sensibility, diagnosticated a 
lesion in the motor centres of the bladder and rectum. 

Treatment 

Where the rectal paresis is secondary, treatment must be directed 
toward the underlying cause. Where this is impossible, or where a 
primary neurosis is present, we should endeavour to improve the 
functions of the incompetent sphincter. For this purpose, faradiza- 
tion of the rectum is of the first importance, and must be carried 
out thoroughly and systematically. The diet should vary with the 
degree of the paralysis. 

If involuntary evacuations occur only when there is diarrhoea, 
the latter must be prevented by suitable dietetic regulations (astrin- 
gent diet). If involuntary evacuations occur when the stools are 
well formed, we must prevent faecal accumulation in the lower 
intestinal segment. By diet we should attempt to have the stools 
semisolid, so that a complete daily evacuation follows. The patient 
must be particularly impressed with the importance of attending to 
defecation regularly, at a certain fixed time of the day. 

Where, despite these precautions, fgeces accumulate in the rec- 
tum, they should be got rid of by enemata of oil or soap water. 
The diseased region should also be stimulated by cold sitz baths 
and frequent irrigations. Of medicinal remedies, injections of 
strychnin (0.001 to 0.002 gram per dose), or suppositories of nux 
vomica (0.03 gram twice a day) are best. 

(d) Nervous Flatulence 

This consists of alternating expulsion from and reaccumulation 
of air within the bowel, similar to nervous eructation. It is seen 
mostly in hysterical girls and women and in neurasthenics, but also 
occurs in healthy individuals. 

The affection may be acute, chronic, or periodical. As yet it is 
but little understood. The best theory is that which attributes it 
to rhythmical contraction and dilatation of the intestine. Anal- 
ogous to what Oser believes to take place in nervous eructation, 
after the air has been expelled from the lower bowel, renewed con- 
tractions draw more air from the upper segments ; this leads to dilata- 
tion, and when the bowel is quite distended the air is expressed, 
etc. In well-marked cases the expressed air is odourless, or only 
slightly mixed with offensive gases. 



570 DISEASES OF THE INTESTINES 



Symptomatology and Diagnosis 

A feeling of tension and pressure predominates ; this may 
increase to severe colicky pain. Occasionally the air is heard rum- 
bling through the gut. The abdomen may be more or less dis- 
tended ; in my cases, however, despite repeated complaints of the 
accumulation and passing of air, abdominal distention was scarcely 
appreciable. Passing of wind affords but little relief. Gases reac- 
cumulate, and the patients are disturbed throughout the day and 
sometimes at night. The symptoms are aggravated by mental dis- 
turbances. 

The diagnosis is made from the clinical phenomena, the course 
of the affection, and the negative abdominal symptoms. 

Treatment 

This should be directed toward the underlying hysterical or 
neurasthenic basis. The forbidding of foods which produce flatu- 
lency is usually ineffectual. Since the patients are generally poorly 
nourished, anaemic individuals, a mixed diet rich in fats is espe- 
cially beneficial. Fluids and soups should be avoided, since they 
often increase the flatulence and the feeling of weight in the stom- 
ach and intestine. Warmth, both internal (valerian, peppermint, 
and caraway teas) and external (warm fomentations), brings relief 
and quiets the excited peristalsis. Of the many remedies recom- 
mended for nervous flatulence, the best are the nux vomica prep- 
arations (extract of nux vomica, 0.01 to 0.03 gram per dose, in 
powder or pills), or extract of Calabar bean (0.05 gram to 10.00 of 
glycerin, 5 to 6 drops t. i. d., or pills, 0.005 to 0.01 gram per dose). 

Where constipation coexists, diet and the magnesia preparations 
(especially magnesia usta) are to be recommended. 

2. Sensory Neuroses 

Enteralgia {Neuralgia Plexus Mesenterial) 

This is a periodic, painful irritation of the intestinal nerves, 
occurring without apparent anatomical cause. Thus enteralgia is a 
true neuralgia, and, as stated by Nothnagel,* must be distinguished 
from the colic of intestinal contraction. The cause is said to be in 
the large nerve plexuses (mesenteric, hypogastric, and cceliac). 

* Loc. cit., p. 489. 



NERVOUS DISEASES OF THE INTESTINES 571 

Romberg has tried to establish separate types of the affection for 
the different plexuses affected. When carefully examined, how- 
ever, the symptoms are so similar that it is almost impossibleto 
differentiate these groups. The very assumption that enteralgia 
is due to disease of the mesenteric plexus is purely theoretical. 
Malaria, lead poisoning, and locomotor ataxia are cited as causes of 
enteralgia. This condition is also found in hysterical and neuras- 
thenic individuals, and Peyer has very often observed it in sexual 
neurasthenics. 

Symptomatology 

Enteralgia presents itself as mild or severe, drawing, cutting, 
boring, and burning pains in the abdomen, particularly in the meso- 
gastrium. The patients take to bed, writhe with pain, and seek 
relief by evacuations or the passing of wind. In severe cases vomit- 
ing may occur and afford the patient temporary relief. 

We shall not discuss in detail the enteric crises of locomotor 
ataxia, but mention that they constitute the purest and most instruc- 
tive types of enteralgia. 

The attacks may cease after several minutes, or, with slight 
remissions, last for hours or days (as in visceral crises). They gen- 
erally cease or become less acute during the night. 

In one of my patients, a man of fifty, whose nervous system was upset by 
intense excitement, severe pain followed each act of an otherwise normal defe- 
cation. Careful clinical examination showed normal intestinal functions and 
stools. 

Galvanism improved his condition, and a sojourn in the mountains entirely 
cured him. 

Objectively, there may be slight tympanitis and local points of 
pain, particularly in both hypochondria (A. Peyer). According to 
my experience, the severe pain complained of is in marked contrast 
with the normal condition of the abdomen. 

Constipation may accompany enteralgia, but, unlike stercora- 
ceous colic, does not constitute a necessary feature of the attack. 
That constipation accompanies enteralgia of longer duration (e. g., 
enteric crises) is explained by the vomiting usually present, and the 
abstinence from food. 

The diagnosis of enteralgia is easily made when its etiology is 
apparent (e. g., locomotor ataxia, arthritis, lead intoxication, hys- 
teria, and neurasthenia). When the etiology cannot be discovered 
the diagnosis is always uncertain. 



572 DISEASES OF THE INTESTINES 

Hepatic, renal, and cystic calculi must first be carefully excluded. 
An irregular cholelithiasis may closely resemble enteralgia. Care- 
ful examinations of the anterior and posterior regions of the liver,, 
questioning regarding icterus, and the finding of concretions may 
aid in the differentiation. In distinguishing from nephrolithiasis 
and cystolithiasis, we must consider the data obtained from palpa- 
tion of the kidney and bladder, examination of the urine, and cys- 
toscopy. Enteralgia can usually be distinguished from flatulent colic 
by the presence of faecal accumulations, or by the irregular char- 
acter of the stools in the latter and by the cessation of the attack 
when large quantities of flatus have been passed. 

Differentiation from true colitis can generally be made by re- 
peated and careful inspection of the stools and by intestinal irriga- 
tion. In this connection we would mention hernise of the linea alba, 
which are easily overlooked, and which often cause gastralgia or 
enteralgia. Adhesions of the intestinal segments may produce all 
the symptoms of severe intestinal neuralgia. 

In some text-books (Rosenheim and A. Pick) peritonitis and 
perityphlitis (A. Peyer) are also considered in this connection. 
When the patient is examined not only during the attack but also 
after its completion, error is almost impossible. 

Treatment 

As enteralgia is not a primary affection, its curability depends, 
upon the underlying disease. In lead colic, complete cure is ac- 
complished by removal of the toxic cause and by the administra- 
tion of appropriate remedies (iodin preparations, sulphur baths, 
etc.). Up to the present time the visceral crises of locomotor ataxia 
have remained rebellious to treatment. The crises of gout are like- 
wise extremely obstinate. In these latter instances, as well as in 
idiopathic enteralgia, we must treat the paroxysms symptomatically 
with hot fomentations, warm enemata, and narcotics (best subcuta- 
neously or in suppositories). Invigorating general treatment is in- 
dicated in neurasthenical or hysterical enteralgias. Galvanization 
of the abdomen and rectum may also be tried. 

3. Secretory Neuroses 

(a) Nervous Diarrhoea 

This condition, first minutely described by Trousseau, is charac- 
terized by more or less numerous thin, watery, generally periodic 



NERVOUS DISEASES OF THE INTESTINES 573 

evacuations. The diarrhoea may result from some central disturb- 
ance (the irritation being carried along the course of the vagi and 
sympathetic), from peripheral irritation (alimentary diarrhoea), it 
may be reflex (disease or displacement of the genital organs, en- 
tozoa, thermic causes, etc.), or may be due to the absorption of toxic 
products. 

In a limited sense, nervous diarrhoea is usually an accompany- 
ing symptom of general nervous debility. This fact must be kept 
in mind, since only by its careful consideration can a positive diag- 
nosis be made and favourable treatment instituted. A more ex- 
tended experience enables us to distinguish several types : The first 
group is characterized by the fact that under the influence of emo- 
tions, or after partaking of certain food or drink, these individuals, 
whose intestinal functions are otherwise normal, suddenly have one 
or several quickly repeated fluid evacuations. 

In the second group the intestines are unstable, a tendency to 
diarrhoea exists, but the patients are otherwise healthy. From 
mental excitement or variations from their ordinary mode of liv- 
ing, sudden severe diarrhceal evacuations occur, which cease after 
the patient is placed under normal conditions. 

A third group is characterized by diarrhoea under special condi- 
tions — for example, when opportunity for defecation does not exist, 
or is surrounded by certain embarrassing difficulties. At other 
times the intestinal function is normal. 

Symptomatology akd Diagnosis 

Apart from the etiology and the periodicity of its occurrence, 
nervous diarrhoea presents no specific features. The number of 
dejections varies largely. The subjective symptoms are the usual 
ones of tenesmus, rumbling, severe thirst, etc. The stools are not 
characteristic. The patients tell us that food has been passed com- 
pletely undigested, but since there is rarely an opportunity for ex- 
amining the stools during an attack this statement must be accepted 
with great reserve. "We shall again refer to the question of mucous 
admixture of the evacuations. Blood is never or very exceptionally 
present. Pus is always absent. 

These diarrhoeas are, so to speak, explosive in character. A 
feeling of intestinal quietude very soon follows an attack developed 
with inconceivable rapidity, and then, aside from a slight weari- 
ness, the patient is relieved and well. In other cases the attack 
begins very suddenly, but if left untreated it may continue 



574 DISEASES OF THE INTESTINES 

many hours or days. I have recently seen a very typical case of 
this kind. 

The etiological factors of the attacks vary, and depend chiefly 
upon the particular psychic idiosyncrasy of the individual. In an 
excellent article on G-astric Neuroses, Fleiner 13 relates how students 
before their first duels, and physicians before applying forceps dur- 
ing labour, previously visit the water closet.* These are examples of 
very acute emotional diarrhoea (diarrhoea produced by fear). In 
chronic cases, occupation frequently determines the attacks. For 
example, I have often observed nervous disorders in bankers and 
stock speculators under the influence of sudden great financial 
crises. In actors, a debut, a gala or a first performance may in- 
duce peristaltic hypermotility. Canstatt 14 reports the case of a 
physician who was attacked with watery diarrhoea before every 
large operation. Numerous other examples might be given. 

Before proceeding to the diagnosis I shall describe several cases 
which illustrate the above remarks. 

I. — Mr. S., wine merchant of Berlin, forty-six years *of age; comes from 
a nervous family, and, as he himself says, has been nervous for years. Was 
formerly addicted to excessive drinking, especially of champagne. Patient is 
married to a very nervous and jealous woman. He complains of the following 
attacks which occur from three to five times yearly : After any great excite- 
ment he is suddenly attacked by severe gastric colic, together with profuse 
diarrhoea. Even the blandest nourishment is passed in a few minutes. The 
attacks last three or four days, during which time the appetite is very poor. 
The patient improves gradually. In the interval between the attacks the gastric 
functions are normal. 

The last attack occurred on June 3, 1898, in consequence of great agitation 
at his home. The patient suffered intense pain, causing him to toss about and 
to break out into a cold perspiration. The pain always begins during the day, 
but ceases at night. It is independent of food ingestion. There are twenty to 
thirty almost watery stools per day, accompanied by severe tenesmus. 

Status Prcesens. — Muscular, florid-looking man ; pulmopary organs normal. 
Marked diffuse sensitiveness to pressure in the gastric region, disappearing 
when the patient's attention is withdrawn. Posteriorly, alongside the verte- 
bral column there are numerous scattered pressure points. Patellar and pupil 
reflexes are somewhat sluggish. No disturbances of sensibility, no Romberg's 
symptom. 

This case gives the impression of a visceral crisis, and we cannot 
exclude the possibility that the above symptoms represent begin- 

* In his celebrated novel Debacles, Zola has forcibly described the reflex action 
upon intestinal peristalsis resulting from the enemy's artillery fire. 



NERVOUS DISEASES OF THE INTESTINES 575 

ning locomotor ataxia. At present, however, corroborative symp- 
toms are absent, so that we may regard the case as one of secretory 
neurosis. The etiology also speaks in favour of this diagnosis. 

II. — Mrs. L. T., of Berlin, aged thirty-three; teacher. For years patient 
has suffered from nervous disturbances of the stomach and intestines; for 
example, vomiting and diarrhoea occurred frequently at examinations. Later, 
this condition improved, but about three months after an operation for fistula 
in ano it returned. Since that time diarrhoea frequently occurs after the 
slightest excitement ; thus the thought of consulting a physician or of meeting 
strangers produces intestinal hyperperistalsis. There is also a predisposition to 
diarrhoea when the patient makes a social call and cannot reach the toilet room 
unobserved. In her own home, however, such attacks do not occur. Diet has 
absolutely no effect upon the attacks — e. g., the stools may be quite normal 
after eating fruit, vegetables, rye bread, or cake. Appetite always good. Pa- 
tient is anaemic, has cold extremities (mains serpentines). Except for mild 
sphincteric paresis all organs are normal. 

Treatment. — Arsenic, which, according to patient, is very successful. 

III. — Mr. L., fifty years old, director of a chemical factory in Boston; 
antecedents of both parents nervous. The sisters of the patient are more or 
less neurotic, but severe diseases of the nervous system have never appeared 
in the family. The patient himself is easily excitable, but is of happy tem- 
perament. 

Has had his present trouble for ten years. It shows itself in occasional 
diarrhoea, which occurs particularly when the patient is prevented from or 
embarrassed in seeking the toilet. This is specially the case during railroad 
trips. He must always ride in a railroad coach containing a toilet. When the 
patient is invited to dinner it often happens that he must leave because of 
sudden intestinal hypermotility. When going to the theatre he always takes 
an end seat, so as to be able to leave quickly if necessary. Otherwise the 
stools are entirely regular; the appetite is fair; sleep and general condition 
good. 

The patient is a strong, well-nourished man. Objective signs (including 
examination of the fasces) are normal. 

IV. — Mrs. G., of Moscow, aged twenty-nine; merchant's wife. The pres- 
ent affection dates back six years, and began with her puerperium. It com- 
menced with severe intestinal colic and rumbling and fluid stools mixed 
with mucus and blood. Improvement after three or four days. Since then 
there has been marked sensitiveness of the intestines, particularly when the 
patient is excited. For example, the colic and diarrhoea begin when she is 
frightened or worried ; once an attack occurred when her child was sick, and 
again when she had toothache and migraine. Rest has a favourable effect. 
Diet has no appreciable influence. In the intervals between the paroxysms 
the patient has normal stool daily or every second day. During pregnancy and 
after labour the attacks are more severe and frequent. 

On June 19, 1898, the patient was admitted to my private clinic for careful 
observation. 

I pass over unimportant details and mention only the intestinal phenomena. 



576 DISEASES OF THE INTESTINES 

There is marked sensitiveness along the entire course of the large intestine, 
particularly over the caecum, the descending colon, and the sigmoid flexure. 

Examination of the Fmces. — These are formed and covered with thick, tena- 
cious mucus. Microscopically there is much degenerated epithelium, in several 
places striated ground substance, in which, by the addition of acetic acid, 
numerous nuclei are seen. Test lavage of the intestine also shows small shredded 
or gelatinous masses of mucus. 

Treatment. — Astringent diet as in chronic diarrhoea. Improvement. On 
June 25th, after a long visit of a relative from Leipzig, she had five fluid evacu- 
ations accompanied by severe pain. Despite fluid diet she had continuous 
tenesmus and about twenty movements during the night of June 25th. The 
stools were brown and watery ; microscopically they showed nothing special. 
Tincture of opium and warm fomentations were ordered. On the next day a 
feeling of marked tension in the abdomen and of great weakness. The stools 
soon became firm and less frequent as the patient rapidly recovered, and left 
the clinic on July 5th. After a course at Franzensbad she was completely 
cured. 

The diagnosis of nervous diarrhoea may be simple or difficult. 
"Where, as in the second and third cases, the nervous factor is pre- 
dominant, the affection occurs periodically with normal conditions 
during the intervals, the diet has no influence upon the course of the 
disease, the clinical examination shows other symptoms of neuras- 
thenia, and the stools exhibit no signs of catarrhal enteritis, the 
diagnosis can readily be made. 

If, however, the condition becomes chronic, the diagnosis is less 
simple. Thus, in the fourth case there is as much ground for as 
against the assumption of a nervous origin. The absence of mucus 
in the dejections — a point on which Nothnagel lays great stress — is, 
according to my own experience and that of von Engelhardt 15 , by 
no means a positive differential fact. Despite the nervous basis of 
the disease, a catarrh may develop, or an otherwise mild clinical 
enteritis may, from mental excitement, suddenly become worse and 
present symptoms of a severe intestinal catarrh. There will be 
mucus in the stools, and yet in both instances the diarrhoea is 
neurotic. 

In his excellent treatise von Engelhardt attempts to introduce 
other facts for the differentiation between true enteritis and intes- 
tinal neuroses. He distinguishes between these two conditions as 
follows : 

Chronic Intestinal Catarrh. — There is generally loss of weight 
and ansemia. "When diarrhoea takes place it is usually during the 
night or in the early morning, and comes on at irregular intervals 
during the day. Diet has a marked effect upon the character of 



NERVOUS DISEASES OF THE INTESTINES 577 

the stool and upon the patient's general condition. There is sensi- 
tiveness to pressure over the colon. 

Intestinal Neuroses. — No loss of weight ; frequently robust 
appearance despite diarrhoea for many years. The diarrhoea gen- 
erally occurs at the usual time of defecation or immediately after 
eating. Evacuations follow one another rapidly, and then cease for 
a long time. Diet has almost no effect upon the attacks, or they 
may cease after a mixed diet. Sensitiveness to pressure over the 
aorta and the iliac arteries. 

The facts cited by von Engelhardt are doubtless of diagnostic 
value, as the clinical histories just given illustrate. In individual 
cases, however, his points of differentiation may leave us in the dark. 
For example, I have repeatedly seen morning diarrhoeas in typical 
neurasthenics whose intestinal functions were otherwise normal. 
Again, the general condition of a patient with intestinal neurosis is 
not, as von Engelhardt maintains, always excellent. In the second 
case I have described I find in my journal " the patient lost 5 kilo- 
grams within a short time." It follows, therefore, that in view 
of the innumerable possible combinations of the protean picture of 
intestinal neurosis, all scientific considerations may occasionally 
mislead. A clear conception of the disease is possible only from 
systematic and most careful observation ; often we can only estab- 
lish the diagnosis from the course of the affection, or from the 
results of treatment. 

Treatment 

This will vary with the type of the disease. The classification 
previously made (page 573) shows that in the intervals between 
attacks the intestinal function is sometimes normal. In such cases 
treatment will be directed toward the general condition, the gen- 
eral and local neurotic irritability, and the diarrhoeas themselves 
when these become excessive. For the last-named condition opium 
is undoubtedly the most appropriate remedy. Dietetic treatment 
is of secondary importance. In continuous intestinal irritability the 
treatment should be different. A diet similar to that of chronic diar- 
rhoea (see pages 224 and 225) will frequently, though not always, 
prevent an attack. In chronic neurotic diarrhoea the same princi- 
ples apply. In addition, hydrotherapeutics, and in some cases 
electricity (galvanism), may be beneficial. For obvious reasons the 
best results are achieved by sanitarium treatment. 

Of medicinal remedies, the bromid preparations (bromid of soda, 



578 DISEASES OP THE INTESTINES 

0.5, one powder t. i. d.) deserve first consideration. According to 
Nothnagel (see also Case II), the arsenical preparations (Fowler's 
solution, 3 to 5 drops t. i. d., in peppermint water) may have a 
favourable effect. For anaemic patients, iron springs (Franzensbad, 
Elster, Pyrmont, Cudowa, Bippoldsau) may be of benefit. Carlsbad 
thermal water taken hot and in small doses is sometimes followed 
by good results.* 

(b) Mucous Colic 

In discussing membranous enteritis (page 228) we mentioned 
mucous colic and the different theories regarding its origin. There 
can be no doubt that periodical membranous dejections are frequently 
observed in neurasthenic and hysterical women. But — and this is 
the distinguishing characteristic — they scarcely ever occur without 
simultaneous habitual (generally spastic) constipation. Since we 
know that in predisposed individuals conditions of obstinate con- 
stipation form the basis for all kinds of nervous and hysterical 
symptoms, we do not consider mucous colic as a symptom of 
hysteria or neurasthenia, but only of constipation. When the 
latter is well marked mucous colic occurs, and it ceases when the 
constipation is no longer present. I do not know of a single 
instance, either from personal observation or from literature, in 
which the mucoid dejections did not cease when the bowels were 
regular. In view of these facts, the theory still maintained by sev- 
eral authors that mucous colic is a secretory neurosis is incorrect. 

It is therefore unnecessary for us to give a separate description of 
this affection ; that in the section on Membranous Enteritis suffices. 

4. Complex Intestinal Neuroses 

Intestinal Neurasthenia 

We have stated (page 521) that abnormal disturbances of func- 
tion may frequently find their outlet along the course of different 
nerves, so that motor, sensory, secretory, and probably also vaso- 
motor disturbances of innervation may be variously combined. In 
this manner there result intestinal conditions similar to those pro- 
duced in the stomach by nervous dyspepsia. 

Cherchewski 16 was the first to give a detailed description of 



* [For corresponding springs and wells in the United States, see pp. 161, 164, 
and 165.— Tr.] 



NERVOUS DISEASES OF THE INTESTINES 579 

intestinal neurasthenia. He directed special attention to three 
characteristic symptoms, viz. : 

1. Habitual constipation, rarely alternating with diarrhoea. 

2. Abdominal distention, particularly in the region of the false 
ribs. 

3. Loud, tasteless, odourless eructations which only exceptionally 
are acid. 

These symptoms are also found in spastic constipation, in nerv- 
ous flatulence, and in membranous enteritis. (Instances of the 
latter condition doubtless figure among the author's cases.) 

Under the term " nervous digestive weakness," Mobius w some 
years ago described a widely different type. In this, despite excel- 
lent appetite and abundant nourishment, the patients, without suf- 
fering any subjective digestive symptoms, become more and more 
emaciated. Their evacuations are apparently normal, but really 
are overabundant, and a large part of their nourishment undoubtedly 
passes away unabsorbed. 

It is well known that, notwithstanding sufficient nourishment, 
individuals may persistently emaciate, but it is questionable whether 
we are not dealing with minute, as yet unknown, anomalies of food 
metabolism. In my opinion, there is at present no reason for a 
special description of intestinal neurasthenia as an individual clin- 
ical picture such as is found in the text- books of Eosenheim and 
Pick. If we possessed a more or less complete clinical syndrome, 
we would be justified in separating this from the other forms of 
intestinal neurosis. Since such is not the case, we must limit our- 
selves to the statement that functional disturbances of the most 
varied kinds may be combined with one another, and thus produce 
an ensemble whose individual traits are entirely dissimilar. 

LITERATURE 

1. Jtirgens. Yerhandl. des III. Congresses f. innere Medicin, 1884, S. 252 ; 

Berl. klin. Wochenschr., 1892, S. 357. 

2. Blaschko. Virchow's Archiv, Bd. xciv, S. 136. 

3. Sasaki. Ibid., Bd. xcvi, S. 287. 

4. Schleimpflug. Zeitschr. f. klin. Medicin, 1885, Bd. ix, S. 40. 

5. Emminghaus. Miinch. med. Wochenschr., 1894, No. 5 u. 6. 

6. Nothnagel. Darmkrankheiten, S. 482. 

7. Peyer. Die nervosen Affectionen des Darms bei der Neurasthenie des 

mannlichen Geschlechtes, Wiener Klinik, 1893. 

8. Kussmaul. Volkmann's Samml. klin. Vortrage, 1878, No. 53. 

9. Boas. Verhandl. des XV. Congresses f. innere Medicin, 1897, S. 479, etc. 
10. Rosenheim. Pathologie u. Therapie d. Krankheiten d. Darms, S. 492. 



580 DISEASES OF THE INTESTINES 

11. Federn. Ueber partielle Darmatonie, Wiener Klinik, 1891 ; Blutdruck u. 

Darmatonie, Wien, 1894 ; Ueber Darmatonie, Wiener med. Presse, 
1895, No. 25-28. 

12. M. Herz. Wiener med. Wochenschr., 1897, No. 36 u. 37. 

13. Fleiner. Archiv f. Verdauungskrankheiten, 1895, Bd. i, S. 243. 

14. Canstatt. Prager Vierteljahrschrift, 1849, iii, 99. Cited from Henoch, 

Klinik d. Unterleibskrankheiten, iii, S. 176. 

15. R. von Engelhardt. Petersburger med. Wochenschr., 1895, No. 48. 

16. Cherchewski. Revue de medecine, 1883, p. 876, etc., and 1033, etc. 

17. Mobius. Centralbl. f. Nervenheilkunde, Bd. vii, S. 4. 



LIST OF SUBJECTS 



Abdomen, inspection of, in intestinal 

diseases. 67. 
Abscess, perityphlitis 486. 

liver, in dysentery, 251, 257. 
Absorption, intestinal, 36. 

from large intestine, 37. 

from small intestine, 40. 

from rectum, 40. 
Acetonuria, 134. 
Acholia. See Stools. 
Achylia gastrica, relation to dyspep- 
tic diarrhoea. 221. 
Acid, acetic. 42, 103, 206. 

biliary, 29, 30, 108. 

butyric, 46, 103, 206. 

caproic, 206, 

carbonic, 45-48. 

ethereal sulphates, 45, 133. 

fatty. 42, 102, 103, 125. 

formic, 206. 

hydroparakumaric, 45. 

lactic, 46, 206. 

oxy-, 46. 

phenyl-acetic, 45. 

phenyl-propionic, 45. 

phenyl-sulphuric, 46. 

propionic. 103, 206. 

succinic, 46, 103, 206. 
Actinomycosis, intestinal, 374. 

complications, 375. 

etiology, 374. 

frequency of. 374. 

pathology, 374. 

prognosis, 376. 

symptoms, 375. 

treatment, 376. 
Adenomata, 365. See Polypi. 
Adhesions, obstructions produced by, 
430. 431. 

strangulation produced by, 410. 
Albumin, determination of, in faeces, 
100. 

digestion of. 37, 140. 
Albuminuria, 134. 
Albumoses, determination of, in 

faeces, 101. 
Ameba. coli (Loesch), 245. 

coli mitis, 247. 

dvsenteriae, 246. 

felis, 247. 



Amebic dysentery. See Dysentery, 

Amebic. 
Ammonia. 47, 48, 
Antipepton. 27. 
Anti-peristalsis, 34. 
Antiseptics, intestinal. 199. 
Anus, inspection of, 77. See Inspec- 
tion, Rectal. 

palpation of, 77. See Palpation, 
Rectal. 
Appendicitis, 468. 

actinomycotic, 475 ; operation in, 
504.' 

American views of, 504. 

as a surgical disease, 505, 509. 

bacteria in. 457. 

complications of, 485 ; chronic in- 
testinal obstruction. 493 ; em- 
boli and thrombi. 492 ; empy- 
ema, 492 ; mode of origin. 492 ; 
pleurisy, 492 ; pylephlebitis, 
492 ; pregnancy. 493 : second- 
ary abscess, 492. 508 ; suppu- 
rative pericarditis. 492 : tho- 
racic and abdominal fistulae, 
492. 

due to dysentery, 254. 

etiology, 472. 

faecal concretions in. 473. 

frequency of, 473, 475. 

larvata, 491. 

operation, contraindications to, 
509 : indications for, 508. 

pathologico-anatomical considera- 
tions, 472, 505. 

pseudo-perityphlitis, 492. 

septic, 492. 

synonyms of, 468. 

treatment, 495, 506 ; conservative, 
495, 506; surgical, 499. 508. 

tuberculous, 475 ; operation in, 503. 
Appendicitis, acute, 468, 471. 

diagnosis from biliary and renal 
colic, 478 ; from caecal tumours, 
345, 489 ; from disease of the 
female adnexa, 488; from in- 
testinal obstruction, 406, 490; 
from typhoid fever. 491 ; in 
unusual positions of the ap- 
pendix, 487, 488. 
581 



582 



DISEASES OF TIIE INTESTINES 



Appendicitis, acute, diffuse, 484 
causes, 484; diagnosis, 485 
differential diagnosis, 490 
surgical treatment of, 500, 
510. 

perforative, 484; differential diag- 
nosis, 490. 

prophylaxis of, 495. 

puncture, intestinal in, 479. 

simple, catarrhal, 478; differential 
diagnosis, 487 ; symptoms, 
478; gastric disturbances, 
4S1; onset, 478; pain, 478; 
pressure sensitiveness, 478 ; 
pulse, 481; temperature, 481; 
tumour, 479; treatment, 49G; 
surgical measures in, 500. 

suppurative, circumscribed, 500 ; 
surgical treatment of, 500, 
510. 

treatment, 495 ; after-treatment, 
498 ; conservative, 49G, 50G ; 
bodily rest, 49G ; diet, 154, 
498; ice, 497, 507; laxatives. 
189, 497, 507; opiates, 154, 
194, 496, 507; prophylaxis, 
495; surgical, 499; indications 
for operations, 502, 508, 509. 

varieties of, 477. 
Appendicitis, chronic, 468, 471. 

diagnosis, 48G. 

diet in, 154. 

etiology, 485. 

massage in, 171. 

obliterans, 486. 

recurring, 485. 

relapsing, 485. 

treatment, 502 ; internal, 503 ; op- 
erative, 503. 

varieties of, 485, 491. 
Appendicostomv. in chronic dysen- 
tery, 269. 
Appendicular colic. 483, 505. 
Appendix, vermiform, 13. 

palpability of, 71. 

surgical anatomy of, 471. 
Applications, moist, 175. 

indications for, 175. 
Atony, intestinal, 565. 

etiology, 565. 

symptoms, 567. 

treatment, 170, 198, 567. 

varieties of, 566. 
Auerbach's plexus, 5. 
Auscultation, abdominal, 84. 

diagnostic value of. 84. 
Axial torsion. See Volvulus. 

Bacteria in faeces, 119. 

bacillus putrificans coli, 121. 
bacillus Flexner, 244. 
bacillus Shiga. 244. 



Bacteria in, bacillus subtilis, 121. 
bacterium coli, 120. 
bacterium lactis aerogenes, 121. 
cholera bacillus, 122. 
Clostridium butyricum, 121. 
cocci, 122. 

decomposition by, 45. 
tubercle bacillus, 122, 289. 
typhoid bacillus, 122. 
Ballottement, 341. 

Bands, obstructions produced bv, 
400. 
omental strangulation produced by, 
400. 
Baths, 168. 

classification of, 168, 175. 
in conjunction with mineral wa- 
ters, 16S. 
therapeutic indications for, 168, 
553. 
Bauhin's valve, 13. 
Belladonna, in intestinal diseases, 

187, 195, 453. 
Bile, 29. 

characteristics and composition, 

29. 
functions of, 29. 
in stomach contents, 130. 
relation to digestion, 30. 
Biliary acids, 29, 30, 108; determina- 
tion of, in faeces, 108. 
gravel in faeces, 111. 
pigments, 30, 93, 107 ; demonstra- 
tion of, in faeces, 107, 108, 111. 
Bilirubin, Biliverdin. See Biliary 

Pigments. 
Blood, condition of, in cancer, 339. 
Blood in faeces, 64, 95, 105, 307, 349, 
357, 534, 538, 550. 
appearance, microscopical, 106, 

117. 
demonstration, chemical, 106 ; mi- 
cro-chemical, 106 ; spectro- 
scopic, 106. 
determination of, 105. 
importance of, in the history, 64. 
sources of, 107. 
Bougieing, rectal, 81. 

diagnostic significance of, 81, S2, 

501.. 
precautions to be observed in, 82. 
therapeutic employment, 83, 541. 
Bougies, rectal, A-arieties of, 81. 
Brunner's glands, 9, 25. 

Caecum, 12 ; tuberculosis of. See 
Tuberculosis, Ileo-caecal. 
tumours of, 303, 344. 
Carbohydrates, determination of, in 
faeces, 102. 
digestion of, 37, 102, 141 ; in the 
.absence of pancreatic juice, 42. 



LIST OF SUBJECTS 



583 



Carcinoma, intestinal, 328. 

ascites in, 333. 

body weight, 332. 

complications, 355. 

condition of blood in, 333. 

cylindrical epithelial, 330. 

diet, 151, 355. 

etiology, 330. 

frequency of, 328. 

general symptoms and diagnosis, 
332. 

glandular enlargements, 334. 

heredity in, 332. 

medullary, 330. 

metastasis, 331. 

oedema of ankles, 333. 

pathological anatomy, 330. 

scirrhous, 330. 

treatment, 357; palliative, 355; 
surgical, 357. 

urine in, 339. 

varieties of, 336. 
Carlsbad Water, in duodenal ulcer, 

331. 
Carminatives, 197. 

Catarrh, acute intestinal, 205. See 
Enteritis, Acute. 

chronic, 212. See Enteritis, Chron- 
ic. 

duodenal, 210. 

of large intestine, 222 ; diagnosis 
of, 222; diet in, 145; mucus 
in, 222. 

of small intestine, 218; diagnosis 
of, 218; diet in, 144; stools 
of, 219. 

mixed forms of, 223. 
Cathartics in intestinal diseases, 186. 

action of, 186. 

administration, endermic, 286; rec- 
tal, 187; subcutaneous, 187, 
282. 

contraindications to the use of, 
189. 

in appendicitis, 189, 498, 507. 

in children, 190. 

indications for the use of, 188. 

in hemorrhoids, 552. 

in membranous enteritis, 190. 

in obstruction and stenosis, 451, 
456. 

in typhlitis, 189, 494. 
Centralkoth, 76. 
Chlorophvl in the faeces, 93. 
Cholesterin, 30. 

determination of, in faeces. Ill, 123. 
Clefts, strangulation produced by, 

500. 
Colic, appendicular, 483, 505. 

flatulent, 282 ; diagnosis from in- 
testinal obstruction, 405 ; opi- 
ates in, 196; treatment, 286. 



Colic, mucous, 578. 

vermicular, 483, 505. 
Colitis, primary, 515. See Perico- 
litis Exudative. 
Colon, ascending, 13. 

descending, 14. 

displacements of, 86, 287, 289. 

transverse, 14. 
Coloptosis, 86. 
Colouring matter, biliary, 30. 

of faeces, 30, 107. 
Compression of bowel, producing ob- 
struction, 432. 
Constipation, 60, 272. 

acute, 60; cathartics in, 188; 
causes of, 60. 

alternating with diarrhoea, 61, 228. 

chronic, 272 ; alimentary, 272 ; 
atonic, 275; cathartics in, 188, 
283; causes of, 61; diagnosis, 
277; diet in, 146, 227, 279; 
electricity in, 282 ; fragmen- 
tary, 275; in carcinoma, 340; 
in chronic enteritis, 223, 227 ; 
in obstruction of large intes- 
tine, 399 ; in stenosis of large 
intestine, 392 ; massage in, 
281 ; mineral waters in. 159 
161, 162, 166; opium in. 187 
predisposing to intestinal cmi 
cer, 61; prophylaxis of, 270 
rectal examination in. 277 
spastic, 275 ; svmptoms. 274 
treatment of, 168, 227. 278. 

habitual, 272. See Chronic. 

mineral waters in, 159. 

significance of. as a svmptom, 60. 
Coproliths, 112. See Stones. 
Crystalline bodies in faeces. 123. 

ammonium-magnesium phosphates, 
126. 

bismuth, 126. 

calcium oxalate, 126. 

calcium phosphate, 125. 

calcium sulphate. 126. 

Charcot-Leyden crystals, 123, 236. 

cholesterin, 123. 

fatty acids, 125. 

fatty soaps, 125. 

haematoidin, 123. 

Decubital intestinal ulcer, 230. 
Diaceturia, 134. 
Diarrhoea. 62. 

acute, 62, 192, 207; diet in, 143, 

211; remedies in, 192. 
chronic, 62 ; causes of, 62 ; diet in, 
149, 224 ; in chronic enteritis, 
219, 223, 224; medicinal reme- 
dies in, 192, 226; mineral wa- 
ters in, 163, 164, 166. 
dyspeptic, 62, 220. 



58± 



DISEASES OF THE INTESTINES 



Diarrhoea, false, 538. 

nervous, 572; diagnosis, 576; from 
chronic enteritis, 576; diet in, 
155, 577; etiology, 573; symp- 
toms, 578; treatment, 577; Va- 
rieties, 573. 
significance of, as a symptom, 62. 
subacute, 192. 
Diet in intestinal diseases, 139. 
fundamental principles of, 139. 
general rules for, 141. 
in acute enteritis, 143, 211. 
in appendicitis and tvpnlitis, 153, 

494, 498. 
in cancer of large intestine, 357. 
in cancer of small intestine, 355. 
in chronic constipation, 146, 227, 

279. 
in chronic diarrhoea, 149, 224. 
in chronic enteritis, 144. 
in diseases of mucous membrane, 

142. 
in duodenal ulcer, 143, 325. 
in functional disturbances, 146. 
in hemorrhoids, 552. 
in membranous enteritis, 237. 
in neuroses, 155. 
in rectal diseases, 156. 
in stenosis and obstruction, 150, 

153, 450, 453. 
in ulcers, 325. 
Digestion, intestinal, 43. 
of albuminoid bodies. 37. 
of carbohvdrates, 37. 
of fats, 38. 

of foods in general, 140. 
Disinfection, intestinal, 199. 
Displacements, intestinal, 20, 287. 
complications, 288. 
diagnosis, 290. 
etiology, 287. 
symptoms, 287. 
treatment, 291. 
Disturbances, gastric, in intestinal 
diseases, 65. 
in acute appendicitis. 481. 
in acute enteritis, 208. 
in cancer, 334. 336. 
in duodenal ulcer, 317. 
in stenosis and obstruction, 382, 
386, 393, 419. See also Vom- 
iting. 
Diverticulum, strangulation produced 

by, 411. 
Douche, rectal, 182. 
Duodenum, 1. 
anatomy of, 1. 

carcinoma of, 334; bilious vomit- 
ing, 335 ; circumpapillary, 
336; diagnosis, 334, 336; diag- 
nosis from pancreatic cancer, 
338; from pyloric cancer, 334; 



from pyloric stenosis, 384, 391 ; 
emaciation in, 338 ; gastric dis- 
turbances, 334, 335; icterus, 
337 ; infrapapillary, 337, pain 
in, 335 ; splashing sounds, 
335; supra papillary, 334; 
symptoms, 334, 335, 337; tu- 
mour, 338 ; vomiting in, 335 ; 
treatment, see Carcinoma, In- 
testinal. 

Duodenum, catarrh of, 210. 

stenosis of, 374; diagnosis, 374, 
377; etiology, 389, 390; gas- 
tric contents in, 377 ; gastric 
disturbances, 376 ; indicanuria, 
377; infrapapillary, 376; me- 
teorism, 376; stools in, 377; 
suprapapillary, 374; symp- 
toms, 374, 376 ; treatment, see 
Stenosis, Intestinal. 

ulcer of, 312. See Ulcer, Duodenal. 
Dysentery, 240. 

abscess, secondary, 251, 257. 

amebse in, 245. 

anasarca in, 258. 

arthropathies of, 258. 

bacteriology of, 243. 

blood in, 261. 

complications of, 251, 255. 

diagnosis, 263; from rectal cancer, 
264, 347 ; from membranous 
colitis, ^64. 

distribution of, 240. 

etiology of, 242. 

faeces in, 259. 

hemorrhage in, 257. 

historical, 241. 

nature and cause of, 241. 

perforation in, 256. 

peritonitis in, 256. 

prognosis of, 265. 

prophylaxis, 265. 

relation to malaria. 242. 

serum reaction of, 262. 

serum therapy in, 269. 

thrombosis in, 258. 

treatment of. 265. 

symptoms, general, 252 ; special, 
254. 

urine in, 261. 

varieties of, 240. 
Dysentery, amebic, 249„ 

diagnosis, 265. 

etiology, 245. 

pathology of, 249. 

prognosis, 265. 

symptoms, 253. 

treatment, 269. 
Dysentery, bacillary, acute, 247. 

diagnosis, 263. 

etiology, 244. 

pathological anatomy, 248. 



LIST OF SUBJECTS 



585 



Dysentery, prognosis, 265. 

serum reaction in, 262. 

symptoms, 252. 

treatment, 265 ; diet, 266 ; hygiene, 
265 ; drugs, 267 ; entero-clysis, 
268; serum therapy, 269. 

varieties of, 247. 
Dysentery, bacillary, chronic, 249. 

diagnosis, 263. 

etiology, 244. 

pathological anatomy, 249. 

prognosis, 265. 

serum reaction in, 262. 

symptoms, 253. 

treatment, 269. 

Electric trans-illumination of intes- 
tines, 88. 
Electricity, 172. 

action of, 173. 

results from, 174. 

technic of, 173. 

therapeutic indications for, 174, 
282, 456, 457. 
Electrode, rectal, 175. 
Emaciation, in chronic constipation, 
277. 

in intestinal cancer, 332. 

in rectal cancer, 351. 
Enemata, rectal, 177. 

antiseptic, 193, 310, 523. 

astringent, 193, 310, 523. 

high, 180. 

indications for, 177, 180, 451, 454, 
494, 553, 569. 

mineral waters in, 165. 

oil, 178. 

technic of, 177, 179. 
Enteralgia, 570. 

diagnosis, 571. 

differential diagnosis, 572. 

etiology, 570. 

opiates in, 196. 

symptoms, 571. 

treatment, 196, 572. 
Enteritis, 205. 

acute, 205 ; alimentary, 206 ; com- 
plications of, 208 ; diagnosis, 
207; diet, 143, 211; etiology, 
205 ; faeces in, 207 ; infectious, 
62, 105; medicinal, 206; re- 
frigeration, 207 ; symptoms, 
209; toxic, 205; treatment, 
210. 

amoebic, odour of faeces in, 94. 

chronic, 212; cathartics in, 190 
course, 217; diagnosis, 217 
diet, 144, 145; etiology, 212 
faeces in, 216; forms of, 214 
mineral waters in, 164, 166 
pathological anatomy of, 213 
symptoms, 214; treatment, 223. 



Enteritis, membranous, 228 ; arti- 
ficial, 230; cathartics in, 190; 
complications, 230, 236 ; course 
of, 236; diagnosis, 236; ene- 
mata in, 237 ; etiology, 229 ; 
stools in, 234 ; symptoms, 230 ; 
treatment, 236. 
Enteroliths, 112. See Stones. 
Enteroptosis, 287. 
Enterospasm, 559. 
diagnosis, 560. 
symptoms, 560. 
treatment, 561. 
Enterostomy in malignant growths, 
358, 365. 
in obstruction, 464. 
Enterorrhagia. See Hemorrhage, In- 
testinal. 
Entozoa, obstruction by, 438. 
Epithelium, in faeces, 117, 235. 
Evacuations, intestinal. See Faeces 

and Stools. 

Examination, rectal, 77. 

digital, 79, 357, 395. 

instrumental, 79. 

manual, 79. 

Excretion, intestinal, 41. 

auxiliary to renal excretion, 42. 
during fasting, 41. 

Faecal tumours. See Tumours, Faecal. 
Faeces, 42, 63, 90. See also Stools. 

admixtures, pathological, in, 64. 

albuminoid bodies in, 100. 

bacteria in, 42. 

biliary matter in, 107, 219. 

bilirubin in, 93. 

blood in, 64, 95, 105, 117, 301. 

calcium salts in, 125, 126. 

carbohydrates in, 102. 

chlorophyl in, 93. 

cholesterin in, 111. 

colour of, 42, 63, 93. 

colouring matter of, 30. 

consistency of, 63, 92. 

crystalline bodies in, 123. See 
Crystalline Bodies. 

effect of diet upon, 42, 93. 

epithelium in, 117, 219. 

examination of, 90 ; arrangements 
for, 91; chemical, 99; diagnos- 
tic value of, 90 ; macroscop- 
ical, 91; microscopical, 113. 

fats in, 102, 219. 

ferments in, 110. 

food remnants in, 42, 65, 97, 113. 

form of, 91. 

frog-spawn bodies in, 96. 

gallstones in, 111. 

importance of careful examination 
of, 63. 



5S6 



DISEASES OF THE INTESTINES 



Faeces, inorganic substances in, 42, 
113, 114. 

intestinal elements in, 117, 302. 

leukourobilin in, 105. 

micro-organisms in, 42, 118. 

mucin in. 117. 

mucus in, 04. 92, 207. 

muscle fibres in, 97, 113, 219. 

nature and composition of, 42. 

odour of, G5, 94. 

odourless, 94, 

pancreatic stones in. 111. 

parasites in, Go, 99. 

phenol in, 109. 

pus in, 64, 95, 117, 301. 

quantity, variations in, 42, 63, 93. 

reaction of, 99 ; determination of, 
99 ; diagnostic significance of, 
100. 

significance of, in the history, 63. 

skatol in, 42, 94, 110. 

soaps, fatty, in, 103. 

starch granules in, 115, 219. 

tumour fragments in, 64, 99, 311. 

urobilin, 107. 

yellow mucous granules in, 96, 
218. 
Fats, determination of. in faeces, 102. 

intestinal digestion of, 38, 104. 
Ferments, determination of, in faeces, 

110. 
Finger cots, 78. 
Fissures, anal, 529. 

diagnosis, 530. 

etiology, 529. 

location, 529. 

symptoms, 530. 

treatment, 530. 
Fistula, rectal, 526. 

diagnosis, 527. 

etiology, 526. 

symptoms, 527. 

treatment, 528. 

varieties of. 526. 
Flatulence, nervous, 569. 

diet in, 156. 

etiology, 569. 

symptoms, 570. 

treatment, 196, 570. 
Flexure, sigmoid, 14. 

displacements of, 23, 290. 

volvulus of, 414. 
Fold, transverse rectal, 18. 
Folds, Kerckring's, 8. 
Food remnants in faeces, 42, 65, 97, 
113. 

significance of, 97. 
Food stuffs, intestinal digestion of, 
140. See also Digestion, Intes- 
tinal. 
Foreign bodies producing obstruc- 
tions, 434, 439. 



Gallstones, obstruction by, 484. 
Gases, intestinal, 46. 
during disease, 48. 
during health, 47. 
intestinal, influence of mesenteric 

circulation, 48, 401. 
influence of peristalsis, 48. 
sources of, 46; from carbohy- 
drates, 47 ; fats, 49 ; proteids, 
48. 
Gastric disturbances. See Disturb- 
ances, Gastric, 
lavage. See Lavage, Gastric. 
Gastro-enteritis, diet in, 143. 

opium in, 192. 
Granules, yellow mucus, in faeces, 96. 
Growths, intestinal. See Tumours. 
Gurgling, ileo-caecal, 84. 

Haematemesis. See Hemorrhage, Gas- 
tric. 
Hemorrhage, intestinal, 143, 157, 
diet in, 142. 

gastric, in cancer of large intes- 
tine, 346; in duodenal ulcer, 
317. 
in cancer of large intestine, 342. 
in duodenal ulcer, 317. 
in hemorrhoids, 550, 554. 
in ileo-caecal tuberculosis, 304. 
in obstruction, 403, 426. 
in ulcerations, 297. 
Hemorrhoids, 546. 
diagnosis, 551. 
etiology, 547. 
sequelae, 549. 
strangulation of, 550. 
symptoms, 550. 

treatment, internal, 552 ; baths, 
553; diet, 552; enemata, 55]; 
laxatives, 552 ; mineral waters, 
553 ; of hemorrhage, 554 ; of 
inflammatory conditions, 555 ; 
of strangulation, 555 ; toilet of 
the anus, 554. 
treatment, surgical, 556; "blood- 
less," 556 ; " bloody," 557 ; 
cauterization, 557; ligature, 
557; local injections, 557; me- 
thodical dilatation of the 
sphincter, 556. 
Hernia diaphragmatic-, 412. 

obstruction from, 40S. 
History, the, 55. 

importance of, in intestinal affec- 
tions, 55. 
scheme for obtaining, 56. 
Hydriatic measures, 175. 
Hydrobilirubin, 30. 
Hydrogen, 45, 48. 

sulphuretted, 45, 47. 
Hydrotherapeutic measures, 158, 2S2. 



LIST OF SUBJECTS 



587 



Icterus, in duodenal ulcer, 318, 324. 

in intestinal cancer, 343. 
Ileum, 3. 

cancer of, 344. 
stenosis of, 390. 
Ileus, 39G. See Obstruction, Intes- 
tinal. 
Ileus, verminosus, 438. See Obstruc- 
tion by Entozoa. 
Iliac phlegmon, 511. 
Indicanuria, 132, 403, 421. 
Indigo red, 133, 404. 
Indol, 42 ; in the faeces, 45, 94. 

determination of, 110. 
Inflation, intestinal, 84. 

diagnostic importance, 85, 86, 342, 

399, 420. 
methods of, 84. 
technic, 85. 

therapeutic employment, 182, 456. 
Infrapapillary carcinoma and steno- 
sis. See Duodenum. 
Injection of water, 86. See Water, 

Injection of. 
Injections, rectal, 177. See Enemata. 
Inspection in intestinal diseases, 67. 
abdominal, 67. 

rectal, 77 ; importance of, 77 ; ob- 
jective results from, 81; tech- 
nic of, 79. 
Intestines, absorptive functions of, 
36. 
actinomycosis of. See Actinomy- 
cosis, 
adenoma of. See Adenoma, 
anatomy of, 1. 
atony of. See Atony, 
carcinoma of. See Carcinoma, 
catarrh of. See Catarrh and En- 
teritis, 
contraction of, regurgitive, 66; 

tetanic, 68. 
disinfection of, 199. 
displacements of. See Displace- 
ments, 
electric transillumination of, SS. 
excretory function, 41. 
gases of. See Gases, 
hemorrhage of. See Hemorrhage, 
histology of, 3. 
inflation of. See Inflation, 
insufficiency of, 575. 
intussusception. See Intussuscep- 
tion, 
invagination. See Intussusception, 
irrigation of. See Irrigation, Rec- 
tal, 
large, 10. See Intestine, Large, 
lavage of. See Lavage, 
lymphosarcoma of. See Sarcoma, 
massage of. See Massage, 
movements of. See Peristalsis. 



Intestines, myoma of. See Myoma. 

neoplasms. See Tumours. 

neuroses of. See Neuroses. 

obstruction of. See Obstruction. 

paresis and paralysis of. See Pare- 
sis. 

peristalsis of. See Peristalsis. 

physiology of, 24. 

polypi. See Potypi. 

puncture of, in appendicitis, 479; 
in obstruction, 479. 

resection of, in malignant disease, 
358, 365. 

sarcoma of. See Sarcoma. 

secreting function, 24. 

small, 1. See Intestine, Small. 

stenosis of. See Stenosis. 

strangulation of. See Strangula- 
tion. 

syphilis of, 298. See also Syphilis. 

tuberculosis of. See Tuberculosis. 

tumours of. See Tumours. 

ulcers of. See Ulcer, Duodenal, 
and Ulcers. 

urine in diseases of. See Urine. 
Intestine, large, absorption from, 40. 

anatomy of, 10. 

atony of. See Atony. 

blood supply, 15. 

carcinoma of, 339 ; appetite in, 
341 ; atypical forms, 343 ; con- 
stipation in, 340; diet in, 151, 
355 ; differential diagnosis be- 
tween csecal tumours and ap- 
pendicitis, 345 ; between malig- 
nant and benign intestinal 
growths, 345 ; from chronic in- 
tussusception, 346 ; from dys- 
entery, 347 ; from floating kid- 
ney, 346 ; ileo-csecal tuberculo- 
sis, 309 ; from intestinal neuro- 
ses, 350 ; from tumours of 
other organs, 346; evacuations, 
342 ; hsematemesis, 340 ; intes- 
tinal rigidity, 342; pain, 339; 
palliative treatment, 355 ; 
stomach contents, 343 ; surgi- 
cal treatment, 357 ; symptoms, 
339, 344; tenesmus, 340; tu- 
mours, 341 ; typical forms, 
339; vomiting, 340. 

catarrh of, 222. See Catarrh and 
Enteritis. 

displacements of, 20, 287. 

electric transillumination of, 88. 

histology of, 15. 

lymphatics of, 15. 

nerves of, 15. 

obstruction of, 397, 446. 

physiology of, 24. 

sarcoma of. See Sarcoma, Intes- 
tinal. 



588 



DISEASES OP THE INTESTINES 



Intestine, large, stenosis of, 392. 

ulcers of, 305 ; diagnosis, 365 ; 
treatment, 310. See also Ul- 
cers, Intestinal. 
Intestine, small, absorption from, 36. 

anatomy of, 1. 

blood supply, 4. 

carcinoma of, 334; diet in, 151, 
355; treatment of, 354, 357. 
See also Duodenum, Carcinoma 
of. 

catarrh of, 218. See Catarrh and 
Enteritis. 

digestive functions of, 43. 

displacements of, 20. 

histology of, 5. 

lymphatics of, 5. 

nerves of, 5. 

obstruction of, 397, 444. 

physiology of, 24. 

sarcoma of.- 361. See Sarcoma, In- 
testinal. 

stenosis of, 384. See Stenosis of 
Small Intestine. 

ulcers of, 305 ; diagnosis of, 305 ; 
treatment. 309. See also Ul- 
cer, Duodenal, and Ulcers, In- 
testinal. 
Intussusception, 421. 

diagnosis. 428 ; differential diagno- 
sis, 346, 446, 546. 

etiology, 422, 424. 

frequency of, 423, 424. 

symptoms, 425 ; evacuations, 426 ; 
meteorism, 426; pain, 425; te- 
nesmus, 426; tumour, 427; 
vomiting, 426. 

terms employed in, 421. 

treatment, internal, 453 ; surgical, 
461. 

varieties of, 422. 
Invagination, 421. See Intussuscep- 
tion. 
Invertin, 46. 
Irrigations, rectal, 180. 

indications for, 180, 494, 523, 541. 

Jejunum, 3. 

cancer of, 338. 

stenosis of, 390. 
Juice, intestinal, 25. 

gastric, in duodenal ulcer, 312, 318. 

pancreatic, 26 ; influence upon in- 
testinal absorption of albu- 
minoids, 37 ; of carbohvdrates, 
38; of fats, 39; in stomach 
contents, 130. 

Kerckring, folds of, 8. 

Kinking, intestinal obstruction due 

to, 430. 
Klebesymptom, Gersuny's, 77. 



Lavage, intestinal, 177. 

gastric, indications for, 183; in car- 
cinoma, 357 ; in obstruction, 
458; technic of, 184. 

in intestinal putrefaction, 200. 

test, 87. See Test Lavage. 
Laxatives, 186. See also Cathartics. 

chemical, 147. 

physical, 147, 190. 

thermic, 148. 
Leucocytosis, in differential diagno- 
sis, 491. 
Leukourobilin, 105. 
Lieberkuhn's glands, 8, 16, 25. 
Lientery, 222. 
Lipoma, intestinal, 367. 
Lymphosarcoma, 361. See Sarcoma. 



Marsh gas, 47, 48. 

Massage in intestinal diseases, 171. 

dangers of, 171, 172. 

indications for, 171, 281, 498, 555. 

technic of, 170. 
Meckel's diverticulum, strangulation 

by, 411. 
Meissner's plexus, 5. 
Mesenteric contraction producing ob- 
struction, 432. 
Meteorism, 59. 

diagnostic significance of, 59. 

in carcinoma of large intestine, 342. 

in intestinal stenosis, 382, 386, 
390, 393. 

in intestinal ulcers, 302. 

in obstruction, 401, 419, 426. 
Methyl mercaptan, 45. 
Micro-organisms in faeces, 118. 
Mineral waters and springs, 158. See 

Waters, Mineral. 
Movements, peristaltic, 31. See Peri- 
stalsis. 
Mucin, determination of, in faeces, 

100, 117. 
Mucus in faeces, 64, 95, 319. 

diagnostic significance of, 95. 

in acute enteritis, 207. 

in catarrh of the large bowel, 222. 

in catarrh of the small bowel, 219. 

in chronic enteritis, 216. 

in membranous enteritis, 235. 

macroscopic appearance, 96. 

microscopical appearance, 117.. 
Muscle fibres in faeces, 97, 113, 219. 
Myoma, intestinal, 367. 

diagnosis, 368. 

location, 368. 

origin, 368. 

rectal, 369. 

symptoms, 368. 

treatment, 370. 

varieties of, 368. 



LIST OF SUBJECTS 



589 



Neoplasms, 328. See Tumours. 
Nervous digestive weakness, 579. 
Neuralgia plexus mesenterici, 570. 

See Enteralgia. 
Neurasthenia, intestinal, 578. 
Neuroses, intestinal, 559. 
complex, 578. 
diet in, 155. 

motor, 559. See Atony and Paral- 
ysis of the Intestine, Entero- 
spasm, Flatulence, Procto- 
spasm, and Tormina Intesti- 
norum Nervosa, 
secretory, 572. See Diarrhoea, 

Nervous, and Colic, Mucous, 
sensory, 570. See Enteralgia. 



Obstipation. See Constipation. 
Obstruction by bands, clefts, fenes- 
tra, and internal herniae, 408. 

diagnosis, 414. 

symptoms, 413. 
Obstruction, intestinal, 396. 

by adhesions, bendings, compres- 
sions, kinking, and mesenteric 
contractions, 430 ; symptoms 
and diagnosis, 433. 

by enteroliths, 437. 

by entozoa, 438. 

by faecal tumours, 440. 

by foreign bodies, 434. 

by gallstones, 434. 

by introduction of foreign bodies, 
439. 

cathartics in, 189. 

diagnosis, 405 ; from appendicitis, 
406 ; biliary and renal colic, 
405 ; cholera nostras and 
Asiatica, 406 ; flatulent colic, 
405 ; peritonitis, 406 ; poison- 
ing, 406. 

differential diagnosis between the 
different forms of, 443. 

dynamic, 441, 448. 

large intestinal, 397, 446. 

paralytic, 441. 

small intestinal, 397, 444. 

spastic, 442. 

symptoms, 397 ; constipation, 399 ; 
general condition, 404; hemor- 
rhage, 403; meteorism, 401, 
426; pain, 398; peristalsis, 
403 ; pressure sensitiveness, 
398; tympanitis, 401; urine, 
403; vomiting, 399. 

through volvulus. See Volvulus. 

treatment, 449, 453 ; diet, 153, 453 ; 
electricity, 456, 463 ; enemata, 
454, 463 ; gastric lavage, 454 ; 
intestinal inflation, 456; intes- 
tinal puncture, 456; medicinal, 



456, 463; opiates, 195, 457; 
surgical, 458. 
Obstruction, intestinal, von Wahl's 
symptom in, 401. 

without physical intestinal changes, 
441 ; diagnosis, 443 ; etiology, 
441 ; symptoms, 443 ; treat- 
ment, 463. 
(Edema of the ankles in carcinoma, 
333. 

in sarcoma, 364. 
Opiates, action of, upon the intes- 
tines, 194. 

in appendicitis, 154, 194, 494, 507. 

in constipation, 187. 

in diarrhoea, 192, 196. 

in proctitis, 523. 

in stenosis and obstruction, 195, 
451, 457. 

Pain and pressure sensitiveness, 72. 

as a symptom, significance of, 56. 

in appendicitis, 56, 72. 

in central nervous diseases, 58. 

in duodenal ulcer, 57, 72. 

in intestinal carcinoma, 334, 335, 
339. 

in intestinal ulcers, 300. 

in peritonitis, 57, 72. 

in rectal carcinoma, 351. 

in stenosis and obstruction, 57, 
382, 399, 426. 

nervous, 58. 

periodic, 58. 

qualities and characteristics of, 56. 

rectal, 59. 
Painfulness, pseudo-, 72. 
Palpation, abdominal, 69. 

importance of, 69. 

in a warm bath, 70. 

of individual intestinal segments, 71. 

technic of, 69, 70. 
Palpation, rectal, 77. 

importance of, 77. 

technic of, 78. 
Pancreatic juice. See Juice, Pan- 
creatic. 

diastase, 28. 

stones, 112. 
Papillary carcinoma and stenosis. 

See Duodenum. 
Paracresol, 45. 
Paralysie reflexe, 441. 
Paresis and Paralysis of Intestine, 
575. See Atony, Intestinal. 

rectal, 568 ; etiology, 568 ; symp- 
toms, 568 ; treatment, 569. 
Peptones, determination of, in faeces, 
101. 

intestinal absorption of, 37. 

occurrence in faeces, 102. 
Percussion, abdominal, 83. 



590 



DISEASES OF THE INTESTINES 



Percussion, objective results from, 83. 

palpatory, 83. 

precautions to be observed in, 83. 

value of, 83. 
Pericolitis, exudative, 513. 

diagnosis, 516. 

pathology, 514. 

symptoms, 515. 

treatment, 516. 
Periproctitis, 524. 

acute, 525 ; symptoms, 525 ; treat- 
ment, 526. 

chronic, 525 ; diagnosis, 525 ; symp- 
toms, 525 ; treatment, 526. 

etiology, 524. 

sequelae of, 524. 
Peristalsis, intestinal, 31. 

agents which influence, 35, 146. 

felt by the patient, 66. 

in disease, 36. 

nervous mechanism of, 34. 

rapidity of. 33. 

varieties of, 32. 

visible, 68, 383, 403, 419. 
Peristaltic restlessness. See Tormina 

Intestinorum Nervosa. 
Peritonitis, localized, massage in, 171, 
172. 

perforative, in duodenal ulcer, 323. 
Perityphlitis, 468. See Appendicitis. 
Peyer's patches, 10. 
Phenol, determination of, in faeces, 

109. 
Polypi, intestinal, 365. 

diagnosis, 367. 

location of, 365. 

metamorphosis of, 366. 

multiple, 366. 

rectal, 367. 

symptoms, 367. 

treatment, 370. 

varieties of, 365. 
Polyposis, general intestinal, 370. 
Postappendicitis, 485. 
Pressure sensitiveness, 72, 222. See 

also Pain. 
Proctitis, 520. 

acute, 520; diagnosis, 521; symp- 
toms, 521; treatment, 522. 

chronic, 52 1 ; diagnosis, 522 ; symp- 
toms, 521; treatment, 523. 

etiology, 520. 

varieties of, 520. 
Proctospasm, 559. 

diagnosis, 560. 

etiology, 560. 

symptoms, 560. 

treatment, 561. 
Prolapse, rectal, 543. 

diagnosis and differential diagno- 
sis, 544. 

etiology, 543. 



Prolapse, symptoms, 544. 

treatment, 545. 
Pseudo-perityphlitis, 491. 
Pus in faeces, 64, 95, 117, 301, 343, 
351, 534, 538. 

significance of, in the history, 64. 
Putrefaction, intestinal, 45. 

bacteria in, 45. 

of carbohydrates, 46. 

of cellulose, 46. 

of fats, 46. 

of proteids, 45. 

products of, in the urine, 132. 

remedies against, 199. 

Randkoth, 76, 400. 
Reaction, Rosenbach's, 133, 400. 
Reactions. See Test. 
Rectum, 16. 

anatomy of, 17, 18. 

carcinoma of, 356 ; appetite in, 
357 ; ballottement, 357 ; ca- 
chexia, 357 ; complications, 
358; diagnosis, 358; differen- 
tial diagnosis between carcinom- 
atous and syphilitic stricture, 
359 ; diet, 362 ; digital explora- 
tion, 357; evacuations, 356; 
metastases, 358 ; pain, 357 ; 
palliative treatment, 361; sur- 
gical treatment, 364; symp- 
toms, 356 ; tenesmus, 357 ; tu- 
mour, 357. 

diet in diseases of, 156. 

diseases of, 520. 

examination of. See Examination, 
Rectal. 

fissures of. See Fissures, Rectal. 

fistula of. See Fistula, Rectal. 

histology of, 19. 

illumination, electric, 80. 

inspection of, 77. 

myoma of, 375. 

paralysis and paresis of, 568. See 
Paralysis, Rectal. 

polypi of, 373. 

prolapse of, 543. See Prolapse, 
Rectal. 

stricture of, 536; diagnosis, 538; 
differential diagnosis, 539; eti- 
ology, 536 ; palliative treat- 
ment, 540; surgical treatment, 
542, 543 ; symptoms, 538 ; 
syphilitic, 537; varieties of, 
537. 

support, 546. 

ulcers of, 532; diagnosis, 534; dys- 
enteric, 532; etiology, 532; 
follicular, 532 ; gonorrhoeal, 
534; symptoms, 534; syphilitic 
533; treatment, 535; tubercu- 
lous, 532; varieties of, 532. 



LIST OF SUBJECTS 



591 



Remedies, mechanical, 170; in chronic 
constipation, 280 ; in intestinal 
obstruction and stenosis, 451. 
medicinal, 186; antidiarrhceal, 190; 
antiputrefactive, 199; contra- 
indications, 194; for flatulence, 
196; indications for, 191; sed- 
ative, 194; tonic, 198. 

Rectoscope, Herzstein's, 80. 

Rigidity, intestinal, 69, 348, 383, 394. 

Rontgen rays, 88. 

Saccharomyces in faeces, 119. 
Salts, inorganic, in faeces, 42. 
Sarcina, in fasces, 119. 
Sarcoma, intestinal, 361. 
diagnosis, 364. 
duration of, 363. 
frequency, 361. 
location, 361. 
metastases, 363. 
relation to tuberculosis, 363. 
symptoms, 363 ; absence of steno- 
sis, 363 ; cachexia, 364 ; gastro- 
intestinal disturbances, 363 ; 
intestinal paralysis, 363 ; 
oedema of ankles, 364; rapid 
growth, 363. 
treatment, 365. 
tumour in, 362, 363. 
varieties of, 362. 
Schafkoth, 92, 351. 
Sedatives, 194; indications for the 

use of, 195, 451, 456. 
Sensations, subjective, 66. 
Sensitiveness, pressure, 72. See 

Pressure Sensitiveness. 
Sigmoid flexure. See Flexure. 
Sigmoiditis, 511. 

acute, 511; symptoms, 511; treat- 
ment, 512. 
chronic, 512; symptoms, 512; 
treatment, 513. 
Sign, adhesive, Gersuny's,* 77. 
Signe de dance, 426. 
Skatol, 42, 44, 94. 

determination of, in fasces, 110. 
Skolikoiditis, 468. See Appendicitis. 
Soaps, calcium, 42. 
fatty, 103, 125. 
magnesium, 42. 
Solitary follicles, 9. 
Sounds, rectal, 81. See Bougies, Rec- 
tal, 
splashing, 73, 335, 567 ; conditions 
necessary to produce, 73 ; 
method of determination, 74; 
significance of, 73, 74. 
succussion, 74. 
Spasm, anal, 529. See Fissure, Rec- 
tal. 
Speculum, rectal, 79. 



Speculum, rectal, cylindrical, 80. 

Czerny's, 79. 

Herzstein's, 80. 

introduction of, 80. 

Kelly's, 80. 

Simon's, 79. 

Sims's, 79. 
Sphincter ani, 18. 
Spray, ether, in constipation, 282. 
Steapsin, 28. 
Stenosis, intestinal, 380. 

chronic, diet in, 150. 

from duodenal ulcer, 325. 

inflation, rectal, in, 85. 

percussion, abdominal, in, 86. 

symptoms, 381; constipation, 382; 
diarrhoea, 382 ; evacuations, 92, 
383 ; gastric disturbances, 382 ; 
meteorism, 382 ; pain, 382 ; 
stasis, 382; visible peristalsis, 
383; vomiting, 383. 

treatment, 412; diet, 150, 450; me- 
chanical, 451; medicinal, 451; 
surgical, 452. 
Stenosis of large intestine, 392. 

differential diagnosis, 395. 

etiology, 395. 

symptoms, 392 ; colic, 392 ; consti- 
pation, 392 ; evacuations, 395 ; 
gastric disturbances, 393 ; me- 
teorism, 393 ; visible peristal- 
sis, 394; vomiting, 393. 

treatment. See Stenosis, Intesti- 
nal. 
Stenosis of small intestine, 384. 

diagnosis of location and cause, 
392. 

differential diagnosis, 391. 

duodenal, 384. See Duodenum, 
Stenosis of. 

jejunal and ileal, 3.90; causes, 390; 
diagnosis, 391; frequency, 390; 
symptoms, 390. 

treatment. See Stenosis, Intesti- 
nal. 
Stomach contents in intestinal dis- 
eases, 129. 

bile in, 130. 

in carcinoma of large intestine, 343. 

in duodenal carcinoma, 334, 336. 

in stenosis of the small intestine, 
387. 

pancreatic juice in, 130. 
Stones, faecal, 112. 

gall-, 111. 

intestinal obstruction by, 437. 

pancreatic, 112. 
Stools. See also Faeces. 

acholic, 94; causes of, 105; de- 
termination of, in faeces, 109; 
diagnostic significance of, 105 ; 
without icterus, 104. 



592 



DISEASES OF THE INTESTINES 



Stools, fatty, 102; causes of, 103. 

in acute enteritis, 207. 

in carcinoma of large intestine, 
342. 

in catarrh of large intestine, 222. 

in catarrh of small intestine, 219. 

in chronic enteritis, 216. 

in hemorrhoids, 550. 

in intestinal stenosis and obstruc- 
tion, 383, 387, 395, 418, 426. 

in membranous enteritis, 234. 

in mucous colic, 578. 

in nervous diarrhoea, 582, 577. 

in rectal carcinoma, 352. 

in rectal strictures, 538. 

in rectal ulcers, 534. 

lienteric, 222. 
Strangulation, by internal herniae, 
411. 

by isolated intestinal adhesions, 
408. 

by Meckel's diverticulum, 411. 

by omental bands, 410. 

of hemorrhoids, 550. 

through clefts and fenestra, 410. 

treatment of, 370. 
Stricture, internal intestinal, 433. 

causes, 433. 

diagnosis, 434. 

intestinal, 380. See Stenosis. 

symptoms, 434. 
Stricture, rectal, 436. 

diagnosis, 538. 

differential diagnosis, 539. 

etiology, 436. 

symptoms, 538. 

treatment, 540. 
palliative, 540. 

bougies, 541 ; cathartics, 541. 
irrigations, 541. 
surgical, 542, 543. 
Substances, inorganic, in faeces, 113. 
Succussion sound, 74. 
Support, rectal, 546. 
Suprapapillary carcinoma and steno- 
sis. See Duodenum. 
Surgical treatment. See Individual 

Diseases. 
Syphilis, intestinal, 377. 

complications, 378. 

diagnosis, 378. 

frequency of, 377. 

pathology, 377. 

prognosis, 379. 

symptoms, 378. 

treatment, 379. 

Teeth, in relation to gastro-intestinal 
catarrh, 67. 

Temperature, types of, in acute ap- 
pendicitis, 481. 

Tenesmus, 65. 



Tenesmus, in cancer of large intes- 
tine, 340. 
in intussusception, 426. 
in rectal diseases, 521, 524, 538, 

550, 560. 
significance of, as a symptom, 65. 
Test lavage, 87. 

diagnostic value of, 87, 218, 219. 
technic, 87. 
Test, Chvostek's, 316. 
digestion, 110. 
Fleischer's, 108. 
Gmelin's, 108. 
haemin, 106. 
Hoyer-Ehrlich's, 118. 
Huppert's, 107. 
Menu's, 207. 
Pettenkoffer's, 108. 
Rieder's, 116. 
Rosenbach's, 133, 404. 
Schmidt's, 108. 
urobilin, 107. 
Weber's, 106. 
^Yidal's, 120, 210, 491. 
Thymol water, 101. 
Tongue, in intestinal diseases, 67. 
Tonics, intestinal, 198. 
Tormina intestinorum nervosa, 33, 
68, 562. 
diagnosis, 565. 
etiology, 562. 
symptoms, 562. 
treatment, 196, 562. 
Toxins, in acute enteritis, 206. 
Trans-illumination, electric, 88. 
Treatment, mechanical, medicinal, 
surgical. See Individual Dis- 
eases. 
Trypsin, 27. 
Tryptophan, 27. 
Tube, electric rectal, 173. 
Tuberculosis, intestinal, 294. 

ileo-caecal, 303 ; diagnosis, 308 ; 

diagnosis from carcinoma of 

caecum, 309; prognosis, 304; 

symptoms, 304; treatment, 310. 

ulcers in, 295. 

Tumours, intestinal, 74, 328. 

benign, 365 ; adenoma, 365 ; lipo- 
ma, 367; myoma, 367; polypi, 
365. 
consistency of, 76. 
diagnosis of nature and situation, 

75o 
diet in, 146. 

faecal, 76, 277 ; diagnosis of, 76, 
448 ; frequent source of error, 
76; obstruction by, 440. 
fragments of, in the faeces, 64, 99, 

343. 
frequency of, 74. 
ileo-caecal, 271, 344. 



LIST OF SUBJECTS 



593 



Tumours, intestinal, in carcinoma of 
large intestine, 341. 

in circumpapillary cancer, 338. 

in intussusception, 427. 

in suprapapillary cancer, 334. 

malignant, 328 ; carcinomatous, 
328; sarcomatous, 361. 

palliative treatment, 355. 

relative mobility of, 75. 

respiratory mobility of, 76. 

sarcomatous, 362. 

sensitiveness of, 76. 

size, variations in, 76. 

surgical treatment of, 357. 

tuberculous, 296. 
Tvmpanites. 59. See Meteorism. 
Typhlitis, 468. 

diagnosis, 476. 

diet in, 154. 

etiology, 470. 

existence of, 469. 

stercoral, 469. 

symptoms, 470, 476. 

treatment, 494. 

Ulcer, duodenal, 312. 

abscess in, 323. 

alcoholism as a factor in, 314. 

carcinomatous, 325. 

complications, 323. 

diagnosis, 3 IS. 

diet. 143, 325. 

differential diagnosis, 321 ; from 
cholelithiasis. 322 ; from gas- 
tric ulcer. 321 ; from hyper- 
acidity, 321. 

etiology, 312. 

gastric juice in, 312. 

hsematemesis, 317. 

icterus, 318, 324. 

intestinal hemorrhage in, 317. 

location of, 314. 

pain in, 315. 

perforation of, 323. 

stenosis from, 324. 

symptoms, 315. 

treatment, 325. 

vomiting in, 317. 
Ulcers, intestinal, 293. 

amyloid, 298. 

catarrhal, 293. 

decubital, 294. 

diagnosis. 304. 

diet in, 143, 145. 

dysenteric, 298. 

embolic, 299. 

evacuations in, 300. 

follicular, 293. 

hemorrhage from, 301. 

large intestinal, 305. 

purulent evacuations in, 302. 

small intestinal, 305. 



Ulcers, intestinal, stercoral, 294. 

symptoms of, 299. 

syphilitic, 298. 

thrombotic, 299. 

treatment, 299. 

tuberculous, 295. 

varieties of, 293. 
Urine, in intestinal diseases, 132. 

abnormal substances in, 132. 

ethereal sulphates in, 134. 

importance of examination of, 132. 

in acute enteritis, 209. 

in intestinal cancer, 333. 

in obstruction, 397. 
Urobilin, 30, 107. 

determination of, in faeces, 107. 

Valve, ileo-caecal, 13. 

insufficiency of, 567. 
Villi, intestinal, 7. 
Volvulus, 414. 

diagnosis, 420. 

etiology, 414. 

frequency, 414, 416, 417. 

indicanuria, 421. 

injection of water in, 420. 

intestinal inflation in, 421. 

of sigmoid flexure, 414. 

symptoms. 417: constipation, 417; 
evacuations, 418; gastric dis- 
turbances, 418; general condi- 
tion, 419; meteorism. 419; 
pain, 418; visible peristalsis, 
419. 

treatment, internal, 453; surgical, 
462. 

varieties of, 415. 
Vomiting, in carcinoma of large in- 
testine, 340. 

in carcinoma of small intestine, 
335, 339. 

in duodenal ulcer, 317. 

in intussusception, 426. 

in obstruction, 399. 

in stenosis of large intestine, 393. 

in stenosis of small intestine, 386, 
390. 

in volvulus, 418. 

stercoraceous, 399. 
von WahFs symptom, 401, 414. 

Water, injection of, per anum, S6. 

diagnostic value of, 86, 342, 405, 
420. 
Waters, mineral, 158. 

alkaline carbonated, 159. 

alkaline, muriated-carbonated, 159. 

bathing, 168. 

benefits derived from use of, 158, 
165. 

bitter, 162. 



594 



DISEASES OF THE INTESTINES 



Waters, mineral, calcareous, 163. 
chalybeate, 164. 
classification of, 159. 
drinking of, 158. 

efiect of, upon peristalsis, 159, 163. 
enemata of, 165. 
free sulphuric acid in, 165. 
in chronic enteritis, 164. 



Waters, mineral, in constipation, 151 
161, 162, 166. 
in diarrhoea, 163, 164, 166, 227. 
in hemorrhoids, 553. 
in nervous diarrhoea, 578. 
in postappendicitis, 498. 
muriated, 161. 
sodium sulphate, 160. 



LIST OF AUTHORS 



Abel, 413. 

Abelmann, 37, 38, 39, 

104. 
Abraham, 133. 
Abrahams, 493. 
Ackermann, 352. 
Akerlund, 118, 229, 235. 
Albers, 317, 469. 
Albert, 370. 
Albrecht, 368. 
Albu, 199, 200. 
Alderhot, 541. 
Allihn, 102. 
Allingham, 527, 531, 

536. 
Alvazzi, 322. 
Anders, 505. 
Arnaud, 242. 
Arnschink, 39. 
Asch, 495. 
Ascher, 242. 
Aubert, 186. 
Aufrecht, 499. 

Baas, 28, 133, 333. 

Babes, 370. 

Bacon, 543. 

Baelz, 240. 

Baer, 521, 534, 536. 

Baumler, 124. 

Baginski, 475. 

Balfour, 31. 

Baltzer, 362. 

Bamberger, 104, 344, 

345, 475. 
Bard, 337, 338. 
v. Bardeleben, 291, 475, 

557. 
Bardenheuer, 359, 366. 
Barker, 461. 
v. Basch, 35. 
Basch, S., 176. 
Basset, 245. 
Bauer, 40. 

Baumann, 45, 132, 133. 
Bauscher, 242. 
Beausennat, 256. 
Bechterew, 35. 
Beck, 471. 



Behrens, 294. 
Belgardt, 41. 
Bell, 164. 
Berard, 329. 
Berg, 370. 
Berggriin, 104, 105. 
v. Bergmann, 346. 
Beriton, 414. 
Berkhan, 70. 
Bernard, 26. 
Bernstein, 26, 43. 
Bertrand, 242. 
Bessel-Hagen, 362. 
Bidder, 26. 
Biedert, 66, 103, 221. 
Bienstock, 121. 
Billroth, 296, 358. 
Birch - Hirschfeld, 298, 

422. 
Bird, 238. 
Blaschko, 559. 
Blauberg,. 101, 102. 
Boas, 27, 28, 43, 68, 74, 

87, 89, 94, 130, 139, 

143, 159, 170, 190, 229, 

237, 292, 386, 451, 536, 

562. 
Boeck, 140. 
Bottcher, 422. 
Bokai, 146, 543. 
Bollinger, 300. 
Borchardt, 470, 474, 

475, 479, 481, 488,491, 

500, 502. 
Bossard, 491. 
Bouchard, 199, 277, 548. 
Boucquoy, 313, 315, 317, 

318. 
Boudet, 455. 
Braam - Houkgeest, 32, 

33. 
Brambillo, 313. 
Brandl, 24, 37. 
Braune, 20. 
Brieger, 45, 110, 132, 

134, 186, 206. 
Brinton, 350. 
Briquet, 399. 
Brissaud, 324. 



Bristowe, 424. 
Brosch, 390. 
Brown, 25. 
Brunton, 250, 282. 
Bryant, 324, 472. 
Budin, 537. 

Bull, 485, 486, 493, 501. 
Bunge, 25, 47, 109. 
Burwinkel, 315, 316, 318. 
Bushe, 521, 537, 541. 



Cahen, 240. 

Calm, 130, 182, 336,386, 

454. 
Calandruccio, 240, 246. 
Calmette, 242. 
Camboy, 258. 
Canstatt, 575. 
Canteloupe, 258. 
Carey, 263. 
Carrington, 361. 
Caspersohn, 487. 
Castelain, 358. 
Celli, 242. 
Chantemesse, 242. 
Cherchewski, 578. 
Chevalier, 230. 
Cheyne, 241. 
Chiari, 374. 
v. Chlapowski, 70. 
Chomel, 335. 
Christomanos, 34. 
Chuquet, 390. 
Chvostek, 134, 316, 317, 

318. 
Clado, 471, 493. 
Claus, 363. 
Codivilla, 325. 
Cohnheim, 471. 
Colberg, 398. 
Coley, 474. 
Collin, 312, 313, 314, 

315, 318, 319, 323, 324. 
Conitzer, 531. 
Conrad, 529. 
Conrath, 296, 303, 310, 

311. 
Copemann, 31. 
595 



596 



DISEASES OF THE INTESTINES 



Councilman, 240, 245, 
248. 249, 250, 251. 

Courmont, 337. 

Courtois, 298. 

Courvoisier, 437, 461. 

Crede, 541. 

Croizet, 519. 

Crook, 160, 164, 165. 

Cruveilhier, 312, 424, 
524. 

Cunningham, 245. 

Curschmann, 21, 22, 23, 
71, 84, 182, 183, 287, 
288, 289, 291, 405, 419, 
453, 454, 455, 458, 460, 
479, 487, 499. 

Czernicki, 241. 

Czerny, 296, 346, 358, 
359, 360, 370. 

Czygan, 334, 335. 

Da Costa, 260, 262. 
Damsch, 84. 
Dance, 424. 
Dauber, 34. 
Davaine, 438. 
Deaver, 501, 507, 510. 
Delfrate, 322. 
Demant, 25. 
Demme, 103. 
Dessauer, 437. 
Deucher, 40. 
Devic, 318. 
Devoto, 135. 
Dickinson, 312. 
Dieffenbach, 542. 
Dietrich, 363. 
Dieulafoy, 230. 
v. Dittel, 557. 
Dobroklonsky, 295. 
Dock, 240. 
Down, 438. 
Dragendorff, 101. 
Drasch, 9. 
Drechsel, 27. 
Dufourt, 461. 
Dujardin-Beaumetz, 199. 
Dumont, 25. 
Dunham, 263. 
Dunin, 273, 274, 283. 
Dunn, 471. 
Durand, 497. 
Durante, 296. 
Duval, 244, 245, 264. 

Eakins, 285. 
Eckehorn, 473. 
Edebohls, 71, 478. 
Ehrlich, 73, 118, 303. 
Eichberg, 240. 
Eichhorst, 40, 173, 318, 
325. 



Einhorn, H., 468, 471, 

473, 475. 
Einhorn, M., 66, 91, 221, 

228, 229, 234, 236, 237, 

507. 
Eisenhart, 294, 295. 
Eisenlohr, 513, 514. 
Ellenberger, 26. 
Eisner, 119. 
Emminghaus, 273, 559, 

566. 
v. Engel, 398. 
v. Engelhardt, 576, 577. 
Engel mann, 33. 
Englisch, 404. 
Engstrom, 368. 
Epstein, 240. 
Escherich, 119. 
v. Esmarch, 18, 346, 526, 

527, 529, 530, 531, 532, 

538, 541, 546, 554. 
Esquirol, 287. 
Ewald, 39, 40, 133, 173, 

183, 185, 228, 229, 282, 

284, 318, 335, 443, 491, 

495, 498. 
Exner, 35. 

Faber, 391, 434. 

Fagge, 401. 

Federn, 566, 568. 

Fellner, 35. 

Fenger, 368, 485. 

Fenoglio, 240. 

Fenwick, 403, 471, 475, 

501. 
Ferrand, 497. 
Feyat, 277. 
Fiebig, 91. 
Fiocca, 242. 
Firth, 200. 
Fischer, 295. 
Fischl, 209. 
Fitz, 471, 473, 474, 475, 

504. 
Fleiner, 179, 227, 237, 

274, 275, 287, 288, 289, 

310, 368, 370, 422, 514, 

574. 
Fleischer, 39, 44, 93, 108, 

109, 209, 284. 
Flexner, 244, 262, 263. 
Fowler, 471, 478, 485, 

488, 493, 501, 507. 
Fraenkel, A., 479. 
Frankel, E., 390, 391, 

493. 
Frank, 404. 
Franke, 238. 
Frerichs, 300. 
Frey, 10. 
I Frick, 25, 26. 



Friedenwald, 74. 
Friedreich, 115. 
Frikker, 438. 
Fromm, 281. 
Fiirbringer, 455, 479. 

Gaffky, 205. 
Galen, 241. 
Galliard, 552, 593. 
Gamgee, 31. 
Gans, 149. 
Gasser, 246. 
Gegenbaur, 13. 
Gemmel, 242. 
Gendron, 492. 
v. Genersich, 85. 
Gerhardi, 336. 
Gerhardt, 104, 125, 492, 

501. 
Gerster, 493. 
Gersuny, 77. 
Gibson, 461, 464. 
Gilford, 365. 
Ginsberg, 38. 
Girode, 301. 
Glenard, 229, 273, 277, 

287. 
Gliicksmann, 326. 
Gmelin, 108, 109, 207. 
Goldbach, 525. 
Goldtdammer, 453. 
Golubeff, 475. 
Goodsir, 119. 
Graser, 445, 455, 463. 
Grassi, 246. 
Grawitz, 294, 501. 
Grisolle, 468. 
Grogorien, 242. 
Grohe, 468, 470, 471. 
Gruber, 28, 491. 
Grundzach, 442. 
Griitzner, 25, 34. 
Gussenbauer, 491. 
Guttmann, 413. 
Gyergyay, 37. 

Hadham, 332. 
de Hiien, 287. 
Hagemann, 48. 
Hagenbach, 342. 
Haguenot, 399, 400. 
Hahn, 346, 365, 385, 386, 

390, 541. 
Hall, 240. 
Hamann, 294. 
Hammarsten, 103. 
Handford, 372. 
Hansemann, 330. 
Hari, 108. 
Harley, 470. 
Hartley, 478, 505, 506. 
Hartmann, 296, 345, 528, 

537. 



LIST OF AUTHORS 



597 



Hasenclever, 183. 
Hauser, 330, 331, 366. 
Hausmann, 331. 
Hedin, 27. 
Hegar, 177. 
Heidenhain, 26, 27, 31, 

37, 39, 43, 442, 456. 
Heidenreich, 438. 
Heimann, 329. 
Heineke, 359. 
Helferich, 366. 
Heller, 438. 
Hemmeter, 82. 
Henle, 10, 12, 19, 399. 
Henoch, 183, 331, 403, 

427, 475. 
Henry, 333. 
Henschen, 231. 
Herczl, 326. 
Hermann, 41, 42, 209. 
Herodotus, 241. 
Heron, 25. 
Herter, 26. 
Hertz, 20, 21. 
Herxheimer, 294. 
Heryng, 88. 
Herz, 113, 130, 336, 386, 

387, 388, 389, 391, 567. 
Herzstein, 80. 
Heubner, 491. 
Heurteux, 370. 
Hiller, 285. 
Hirsch, 24, 36. 
Hirsch, A., 240. 
Hirschler, 141. 
Hlava, 240. 
Hlawacek, 487. 
Hochenegg, 352, 359, 

427, 444. 
Hochhaus, 130, 386, 388. 
v. Hochs tatter, 487. 
'Hoffa, 170. 
Hofmeister, 26, 37, 296, 

390, 452. 
Hofmokl, 77, 423. 
Hollander, 370. 
Holtmann, 366. 
Honigmann, 41. 
Hoppe-Seyler, 25, 37, 38, 

94, 95, 102, 103, 113. 
Hospel, 258. 
Hover, 118. 
Huber, 40, 438. 
Huppert, 107. 
Hutchinson, 366. 
Hyrtl, 3, 18. 

Illich, 374. 

Illoway, 240. 

Israel, J., 346, 404, 435, 

442, 491, 543. 
Iversen, 331. 



Jaccoud, 399. 

Jacobj, 195. 

Jaffe, 132, 133, 403, 404. 

v. Jaksch, 101, 102, 103, 
104, 105, 106, 110, 111, 
119, 121, 123, 125. 

Janicke, 337. 

Jaworski, 130, 226. 

Johnson, 391, 493. 

Josue, 256. 

Jullien, 521, 534. 

•lurgens, 558. 

Kader, 48, 401. 
v. Kara j an, 390. 
Karewski, 473, 475, 479, 

480, 482, 487, 491, 504. 
Kartulis, 240, 242, 245, 

246, 249, 250, 257, 258, 

267. 
Kast, 133, 333. 
Katz, 104, 105. 
KaufTmann, 100, 183. 
Kaulich, 134. 
Kelling, 431. 
Kelly, 80. 
Kelsey, 78. 
Kelynack, 471. 
Kernig, 328. 
Kirmisson, 437. 
Kitagawa, 96, 230, 234, 

235. 
Kjeldahl, 101. 
Kjellberg, 209. 
Klebs, 294, 295. 
Kleinwachter, 499. 
Klemperer, 333. 
Kobert, 40, 41, 198. 
Kobler, 209, 276. 
Kocher, 382, 455, 459. 
Kobner, 535. 
Konig, 296, 308, 341, 

358, 410. 
Korte, 296, 358, 435, 

437, 442, 455, 471, 474, 

478, 479, 485, 488, 493, 

501, 502, 504, 541. 
Kostlein, 437. 
Kohlenberger, 40. 
Kohlstock, 285. 
Kohn, 348. 
v. Koranye, 374. 
Kovacs, 240. 
Kossobudskji, 555, 556. 
Kraft, 493. 
Kraske, 331, 351, 352, 

353, 359, 360, 361. 
Krauss, 312, 317, 318, 

324. 
Krausshold, 345, 472. 
Kronlein, 358, 470. 
Krokiewicz, 308. 



Kriiger, 361, 362, 364. 
Krukenberg, 370. 
Kruse, 240, 244, 245, 

246, 249, 250. 
Krysinski, 230. 
Kuhne, 27, 43. 
Kukula, 338. 
Kummel, 471, 477, 485, 

501, 503. 
Kuster, 183, 468. 
Kiittner, 390, 400, 415. 
Kuhn, 82, 183. 
Kundrat, 361. 
Kussmaul, 36, 183, 336, 

394, 454, 456, 562, 565. 

Lafforgue, 471. 

Lafleur, 240, 245, 248, 
249, 250, 251. 

Lambl, 245. 

Landau, 287, 314. 

Landerer, 326. 

Lange, 326, 557. 

de Langenhagen, 228, 
229, 230. 

Langerhans, 427. 

Langermann, 238. 

Lannelongue, 548. 

Lannois, 305, 337. 

Lanz, 475. 

Lappe, 25. 

Lartigau, 243. 

Laveran, 258. 

Lauenstein, 479. 

Lehmann, 25, 26, 40, 48. 

Leichtenstern, 112, 124, 
125. 287, 335, 381, 386, 
396, 399, 405, 410, 411, 
412, 416, 417, 423, 424, 
432, 438, 441, 442. 

Lennander, 324, 326, 470, 
471, 475, 482, 488. 

Lennhof, 70. 

Lentz, 244. 

Leo, 83, 110, 111. 

Letcheff, 230. 

Letulle, 384. 

v. Leube, 40, 130, 143, 
177, 289, 295, 305, 318, 
332, 335, 442, 451, 512. 

Leubuscher, 173. 

Levy, 359. 

Levy-Dorn, 271. 

Lewandowski, 89. 

Lewin, 541. 

Lewis, 245. 

v. Leyden, 196, 230, 355, 
479. 

Libman, 361, 364. 

Liebig, 186. 

Liebmann, 102. 

v. Liebermeister, 283. 



598 



DISEASES OF THE INTESTINES 



Ling en, 415. 

Link, 368. 

Litten, 134, 234, 391, 

400. 
Lloyd, SOS. 
Lobas, 240. 
Lobstein, 435, 461. 
Lockwood, 325, 370, 505, 

507. 
Losch, 210. 
Lovinsohn, 359. 
Lowenstein, 234. 
Longuet, 234. 
Lorenz, 134. 
Louyer, 468. 
Lubarsch, 330. 
Ludloff, 464. 
Ludwig, 26, 38. 
Luschka, 366, 471. 
Lutz, 240. 

McArthur, 493. 
McBurney, 70, 408, 471, 

501, 504, 505, 507, 508, 

509, 510. 
McCosh, 493. 
McMurtry. 471. 
McNutt, '507. 
Macdonald, 555. 
Macfadyen, 44, 45, 73, 

118. 
Mackenzie, 325. 
Maclagan, 437. 
Madelung, 362, 363, 364. 
Maisonneuve, 310, 358. 
Maixner, 134. 
Makins, 366. 
Malgaigne, 406. 
Manlev, 470. 
Mannaberg, 123, 482. 
Manning, 25. 
Marchand, 231. 
Mariage, 470. 
Martini, 244. 
Marx, 493. 
Massiutin, 240, 246. 
Mathieu, 228, 229, 230, 

558. 
Matterstock, 468, 472, 

473, 474. 
Maurin, 472. 
Maydl, 329, 331. 
Mayer, 35, 317. 
Mayor, 511, 512, 516. 
Menu, 107. 
Melchior, 294. 
Melchioris, 416. 
Melier, 468. 
Meltzer, 44. 
Mendelson, 228. 
v. Mering, 24, 26, 28, 36, 

38, 314. 



Messter, 133. 
Meusser, 470. 
Meyer, L., 433. 
Meyer, W., 510. 
Michel, 365. 
Mikulicz, 325, 351, 435, 

482, 501. 
Miller, 47. 
Minich, 112. 
Minkowski, 26, 37, 38, 

39, 86, 104. 
Mirallie, 338. 
Mislawski, 35. 
Mitchell, 259. 
Miura, 25. 
Mobius, 578. 
Monod, 483. 
Moreau, 186. 
Morgagni, 287. 
Moritz, 24, 36, 314. 
Morris, 473. 
Morton, 501, 504. 
Mosler, 438. 
Mracek, 377, 378. 
Miihlhauser, 209. 
Miiller, 38, 40, 41, 103, 

104, 125, 132, 140, 333, 
363. 

Munde, 493. 

Munk, I., 37, 38, 39, 40, 

41. 
Murphy, 472, 499, 501. 
Musculus, 28. 
Musgrove, 244. 
Musser, 240. 
Mynter, 501, 507, 510. 

Nairn, 370. 

Nasse, 35, 186. 

Naumann, 481. 

Naunyn, 332, 400, 403, 
420, 435, 436, 445, 458, 
460, 461, 462, 487, 488, 
548. 

Nay, 468. 

v. Nencki, 28, 44, 45, 73, 

105, 118. 
Neumeister, 31, 39. 
Nickel, 538. 
Nicolaysen, 346, 358. 
Niemeyer, 260. 

v. Noorden, 41, 103, 190, 
237. 

Nothnagel, 32, 33, 34, 47, 
62, 68, 69, 75, 77, 95, 
96, 97, 100, 104, 105, 

106, 109, 113, 114, 116, 
121, 123, 124, 133, 146, 
173, 181, 183, 194, 213, 
216, 217, 219, 220, 228, 
230, 235, 273, 276, 284, 
300, 305, 318, 329, 342, 



347, 361, 363, 382, 383, 
393, 394, 395, 396, 399, 
403, 420, 422, 424, 443, 
444, 445, 448, 453, 462, 
468, 470, 474, 475,477, 
483, 491, 492, 498, 547, 
548, 560, 562, 563, 573, 
578. 

Nuttal, 118. 

Nylander, 102. 

Obalinski, 401, 403, 459, 

462. 
Obrastzow, 71, 72, 296, 

308. 
Oesterlein, 125. 
v. Oettingen, 464. 
Ogata, 242. 
Oppenheimer, 312, 315, 

316, 317, 318. 
Oppler, 66, 131, 221, 227. 
Oppolzer, 506. 
Orth, 295, 298. 
Ortweiler, 132, 133, 141. 
Oser, 344, 569. 
Osier, 505, 507. 
Otto, 38. 
Ozenne, 230. 

Pacanowski, 134. 

Paci, 368. 

Passler, 346. 

Paget, 366. 

Pal, 35, 514, 515, 516. 

Pariser, 100, 235. 

Park, 263. 

Pasquale, 240, 245, 246, 

249, 250. 
Paton, 31. 
Pauly, 313. 
Pawlow, 222. 
Pean, 541. 
Peiper, 400, 438. 
Pel, 104. 
Pellizari, 370. 
Penzoldt, 154, 167, 179, 

278, 279, 280, 281,282, 

474, 479, 480, 495, 496, 

497, 498. 
Pepper, 505, 507. 
Perewoznikoff, 39. 
Perroncito, 124. 
Perry, 312, 313. 
Petrina, 390. 
Pettenkoffer, 108. 
Petters, 134. 
Peyer, 501, 562, 571, 572. 
Pfannenstiel, 370. 
Pfeiffer, 240. 
Pfltiger, 35. 
v. Pfungen, 133. 



LIST OF AUTHORS 



599 



Pic, 335, 336, 337, 338, 

386. 
Pick, 483, 572, 577. 
Pilliet, 296. 
Planer, 47. 
Plosz. 37. 
Podolinski, 27. 
Polchen, 500, 538. 
Pohl. 195. 
Poisseuille, 186. 
Pollak, 183, 184. 
Pollatschek, 165. 
Port, 366. 
Porter. 470. 
Potain, 260, 349, 415. 
Power, 422, 424. 
Praussnitz, 140. 
Pravaz, 475. 
Prazmowski, 121. 
Preismann, 556. 
Prior, 242. 
Pringle, 242. 
Prochownick, 366. 
Pulawski, 129. 

Quenu, 528, 537. 
Quincke, 93, 94, 126, 154. 

177. 

Radziejewski, 186. 
Raffinesque, 424, 427, 

429. 
Ramm, 198. 

Rauber, 1, 8, 9, 10, 17. 
Reckmann, 312, 313, 317, 

318. 
Regnault - Beclard, 48, 

411. 
Relm. 365. 
Reiche, 3S6. 
Reiclimann, 88. 
Reinbach, 549. 
Reinke, 390. 
Reisert, 48. 
Rendu, 491. 
Renvers, 472, 479, 499, 

501. 
Rewidzoff, 396. 
Ribbert. 330, 468, 471, 

472, 474. 
Richardiere, 231. 
Richardson, 282, 4S1, 

499. 
Richelot, 345. 
Ricker, 363. 
Riedel, 432, 488. 515. 
Rieder. 432, 537, 538. 

541, 543. 
Riegel, 34. 130, 386, 387. 
Ris, A. del, 251. 
Roberts, 27. 
Robin, 318. 



Robitschek, 134. 
Robson, 31. 
Pochard, 437. 
Rohmann, 25, 31. 
Roesen, 124. 
Rokitansky, 329. 
Romberg, 571. 
Rommelare, 333. 
Roos, 94. 
Rosenbach, 84, 133, 333, 

455, 500, 565. 
Rosenheim, 228, 279, 

280, 284, 512, 552, 556, 

565, 572, 579. 
Rosenstein, 38, 39, 40, 

47, 399. 
Rosi, 370. 
Rosin, 133. 
Rossbach, 43. 
Rothmann, 229, 231, 235. 
Rotter, 471. 475, 477, 

4S1. 484, 485, 488, 492, 

496, 499, 500, 501, 502, 

503, 542. 543. 
Roux, 318, 471, 479, 557. 
Rovighi, 199. 
Rubner, 39, 99, 139, 140. 

141. 
Riipp. 329, 331, 345. 

346, 349, 350, 364. 
! Ruge, 47. 229. 
I Rumpel, 133. 
| Runeberg, 84. 
i Ruvsch, 287. 
S Rvdygier, 462, 464. 

I Sahli, 450. 469, 474, 479, 
405. 499. 501. 

Salkowski, 40, 45, 132. 
133, 135. 

Salzer, 290, 310, 346. 

v. Samson, 22. 

Sanders-Ezn, 32. 

Sandmeyer, 37, 40, 104. 

Sandowski, 516. 

Sandoz, 442. 

Sands, 504. 

Sappey, 8, 9, 11, 15. 

.Sasaki, 559. 

Scarbinato. 286. 
I Schafer, 198. 
| Schardinger. 246. 
! Schede. 345. 402. 459, 
464. 471, 501, 543. 

Schiefferdecker, 22. 
; Scbierbeck. 47. 

Schillbach.' 173. 

Schlange, 359. 401, 403. 

Schleimnug. 559. 

Schloffer, 364. 
, Schmidt. Ad.. 97, 108, 
I 117, 219, 235. 



Schmidt, C, 26, 98, 99, 

100. 
Schmidt, R., 363, 364. 
Schmitz, 199. 
Schnetter, 89. 
Schnever, 333. 
Schnitzler, 403, 433, 446. 
Schreber. 281. 
Schrotter, 325. 
Schuberg, 246. 
Schuchardt, 541. 
Schiile, 130, 386, 388. 
Schuler, 461. 
Schulze, 313. 
Schuster, 70. 
Schwab. 366. 
See, 70, 228, 230. 
Senator. 40, 132, 183, 

491. 501. 
Senn, 370, 485, 486. 
Sennertus, 241. 
Shaw, 312, 313. 
Sheild, 312, 322, 489. 
Shiga, 2^, 243, 262, 263, 

269. 
Sick, 437. 

Sieber, 44, 45, 73, 118. 
Simon, 79, 86, 438. 
Siredev. 228. 
Skliffassowski, 370. 
Small, 474. 
Smith. 366. 
Sodre, 256. 

Sonnenburg. 153, 471, 
473, 475, 477, 478, 479, 
483, 484. 435, 488. 4^9. 
490, 502, 503, 504, 500, 
542. 
Soulier, 555. 
Sprouch. 244. 
Stadelmann. 29, 125. 
Starke, 317. 
Stein, 506. 

Steiner, 368, 369, 474. 
Stengel. 240. 
Stiller, 209. 
Stohr, 6. 7. 
Stokes. 441. 
Strauss. 47, 143, 442. 
! Strehl, 442. 
| Stromayr, 134. 

Strong, 244. 
I Striimpell, 209. 
Subbotin, 198. 
Suffit, 2y8. 
Swiezynski, 34. 
v. Sydow, 472. 

Tacke, 48, 401. 
Talamon, 4b8, 469, 474, 

483, 491. 
Talma, 560. 



600 



DISEASES OF THE INTESTINES 



Tappeiner, 47. 

Tavel, 473. 

Teichmann, 40, 104. 

Terrillon, 492. 

Thiem, 542. 

Thierf elder, 103, 113, 
118. 

Thiersch, 330. 

Thiry, 25. 

Thomas, 422. 

Thomson, 268. 

Tietze, 403. 

Tiffanv, 507. 

Treub,* 493. 

Treves, 57, 338, 339, 340, 
362, 398, 399, 400, 408, 
410, 411, 417, 418, 419, 
420, 424, 427, 428, 429. 
430, 431, 437, 444,455, 
459, 471, 472, 475,479, 
483, 485, 488. 

Trommer, 102. 

Trousseau, 541, 572. 

Tschitschowisch, 295. 

Turner, 471. 

Turbv, 25. 

Turner, 209. 

Tyson, 507. 

Ullmann, 234. 
Unna, ooo. 

v. Vamossy, 195. 
Vandenbossche, 251. 
Vanni, 229. 
Vanvers, 483. 



Varr, 446. 

Vaughan, 206. 

van den v'elden, 46. 

Vedder, 244, 264. 

Verneuil, 556. 

Virchow, 96, 287, 302, 

330, 432, 534, 540. 
Villermay, 468. 
Vivaldi, 240, 242. 
Votsch, 276, 287. 
Voit, 30, 40, 42. 
Volz, 475, 496. 
Vries, 133. 

Wagner, 84. 

v. Wahl, 401, 402, 429, 

445. 
Waldeyer, 330. 
Wallis, 391. 
v. Walther, 39. 
Walton, 164. 
Wannach, 326. 
Wassiljeff, 94. 
Weber, 106. 
Weecke, 336. 
Wegele, 279, 280, 386. 
Weir-Mitchel, 291. 
Weiske, 140. 
Wendt, 34. 
Wenz, 26. 
Wernich, 390. 
Westphalen, 431. 
White, 238. 
Whitehead, 366, 558. 
Wiczkowski, 284. 
Widal, 120, 210, 491. 



Wiedersheim, 39. 

Wieland, 501. 

Weir, 504. 

Wiener, 507. 

v. Wild, 279, 282. 

Will, 39. 

Williams, 282. • 

van der Willigen, 531. 

Wilms, 336, 386, 403. 

Windscheid, 513. 

Winston, 31. 

Winternitz, 199. 

Wittich, 110. 

Wittstock, 311. 

Wolfler, 357, 358, 370, 

483. 
Wollbrecht, 518. 
Wood, 285. 
Woodward, 43, 242, 256, 

259, 260, 268. 
Wunderlich, 343. 
Wyss, 294. 



Zancoral, 242. 

Zander, 172. 

Zadawsky, 26. 

Zawarykin, 39. 

Zemann, 328. 

Ziegler, 298. 

v. Ziemssen, 84, 86, 173, 

357, 455. 
v. Zoge-Manteuffel, 401, 

402, 403. 
Zuckerkandl, 468, 474. 
Zuntz, 48, 401. 



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MM 24 1904 



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